Source · Prevention of Future Deaths

Rodney Hampshire

Ref: 2017-0236 Date: 26 Sep 2017 Coroner: Jennifer Leeming Area: Manchester (West) Responses identified: 1 / 1 View PDF

The surgical ward currently lacks monitored beds, which a review suggests could potentially save lives by improving patient surveillance.

Date 26 Sep 2017
56-day deadline 21 Nov 2017 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The surgical ward currently lacks monitored beds, which a review suggests could potentially save lives by improving patient surveillance.
View full coroner's concerns
During the inquest evidence was given that the division of surgery at Salford Royal Foundation Trust is conducting a review examining the benefits of having a small number of monitored beds on the surgical wards such as the ward to which Mr Hampshire had been transferred_ Whilst there was no evidence that this would have affected the outcome in this case, evidence was given that monitored beds of the type envisaged would potentially save lives:

Responses

1 respondent
Salford Royal NHS Trust NHS / Health Body
21 Nov 2017 PDF
Action Taken

Salford Royal NHS Foundation Trust implemented an 8-bed H6 Monitored Unit in June 2017 and is planning an Extended Recovery Unit to optimize post-surgical patient care, reduce complications, and facilitate appropriate use of critical care beds. (AI summary)

View full response
Dear Professor Leeming, Re: Rodney Hampshire (Deceased) Response to Regulation 28: Report to Prevent Future Deaths to Pennine Acute Hospitals NHS Trust: Please find below the response of Salford NHS Foundation Trust ('the Trust") following the inquest into the death of Rodney Hampshire on 15 September 2017 and the Regulation 28 Report which you issued on 26 September 2017 . Your concerns were set out in the Regulation 28 Report as follows, at section 5: During the inquest, evidence was given that the Division of Surgery at Salford Royal Foundation Trust is conducting a review examining the benefits of having a small number of monitored beds on the surgical wards such as the ward to which Mr Hampshire had been transferred. Whilst there was no evidence that this would affected the outcome in this case, evidence was given that monitored beds of the type envisaged would potentially save lives_ KIC RECEIVED Royal have

Review examiningthe_benefits of_having asmallnumber_of_monitored_beds on_the surgicalwards at Salford Royal 2 In October 2017 , a proposal was together with regard to the effective post-surgical management of patients in the post-surgical setting: It was confirmed in this proposal that two initiatives were to be used to provide optimal management of patients in the post- surgical setting: H6 Monitored Unit. An Extended Recovery Unit H6 Monitored Unit 3 The H6 Monitored Unit was implemented in June 2017 at Salford Royal. The Unit is an 8 bed unit adjacent to Critical The unit provides level 1 care (the Intensive Care Society defines this as critical care for "patients in need of additional monitoring/clinical interventions, clinical input or advice") t0 elective and non-elective surgical patients_ The unit provides invasive monitoring and optimisation of patients' care by experienced nurses under the management of the surgical teams. This Unit provides care for those patients who do not require critical care, but require closer management than is provided on the general surgical wards This allows for close monitoring of acute deterioration or post-surgical complications by a specialist team with a high patient to nurse ratio. Extended Recovery_Unit Model 5_ Salford Royal are currently progressing an Extended Recovery Unit Model for surgical patients. It is expected that the Extended Recovery Unit will be in place by quarter 1 2018, after the Trust has obtained the necessary for the unit. The immediate period post-surgery is associated with the acute complications of surgery and there is potential during this period for patient deterioration. It is expected that the Extended Recovery Unit will: i) ensure the optimisation of patient care post-surgery; ii) reduce complications post-surgery; and put Care funding

iii) facilitate the appropriate use of critical care beds_ The Extended Recovery Unit will allow for patients to be monitored following surgery by medical and nursing teams experienced in the management of these patients. This group of patients would otherwise be transferred to critical care or managed on a surgical ward. 8 It is intended that the Unit will provide extended recovery to patients for a 48 hour period within an environment adjacent to the theatres: 9_ The Extended Recovery Unit will allow the close management of patients by experienced staff trained to manage higher care patients_ It is intended that the Unit will be staffed by anaesthetists with the input of the surgical teams_ The Unit will manage patients to a level 1 of critical care (the Intensive Care Society defines this as critical care for "patients in need of additional monitoring/clinical interventions, clinical advice") The nursing ratio is nurse to 3 patients and the unit will have therapy teams input or supporting that are sat within the surgical division, The unit patients will be assessed daily by consultant
10. Those patients requiring level 2 care would be directly transferred to critical care post operatively. hope that this response provides some level of assurance to you and Mr Hampshire's family that Salford Royal NHS Foundation Trust has worked hard to put provisions in place to assist with the effective managerent of patients in the post-surgical setting. Please do not hesitate to contact me if you require any further information in relation to our response

Report sections

Investigation and inquest
On 19th May 2017 I commenced an investigation into the death of Rodney Hampshire, 78 years of age. The investigation concluded at the end of the inquest on 15th September 2017 _ The conclusion of the inquest was Rodney Hampshire died as a consequence of naturally occurring heart and kidney disease precipitated by the challenge of surgery for Colorectal Cancer and Hernia Repair. The cause of death was: 1a) Ischaemic Heart Disease
2) Resection of Metastatic Colorectal Cancer and Parastomal Hernia Repair , Hypertension related Chronic Kidney Disease (Stage 3), Bronchopneumonia:
Circumstances of the death
On the 12t May 2017 Rodney Hampshire underwent bowel surgery at Salford Royal Hospital following which he was admitted to the Intensive Care Unit where he remained until the 15th May 2017 when he was transferred to a surgical ward_ On the 16t 2017 he suddenly deteriorated and sustained a cardiac arrest_
Action should be taken
In opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action:

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Report details

Reference
2017-0236
Date of report
26 September 2017
Coroner
Jennifer Leeming
Coroner area
Manchester (West)

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Nov 2017 (estimated).

Sent to

Salford Royal Foundation Trust

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