Source · Prevention of Future Deaths

James Mallett

Ref: 2017-0075 Date: 16 Mar 2017 Coroner: Yvonne Blake Area: Norfolk Responses identified: 1 / 1 View PDF

Nursing staff lacked the knowledge and experience to perform neurological observations and respond to serious injuries, leading to delayed medical attention, poor record-keeping, and an absence of falls prevention or care planning. The hospital lacked systems to address staff inexperience.

Date 16 Mar 2017

56-day deadline 11 May 2017 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

During (he course of the inquest the evidence revealed malters giving rise to concern: In my opinion there is a risk that future dealhs will occur unless action is taken: : [1) It became clear during evidence that the nursing staff on duty on 13 November 2016 were not able to understand and carry out proper neurological observations: This became evident when on one set of observations the nurse assessed Mr Malletts Glasgow Coma scale (GCS) as 3 (lowest score possible) and yet still had equal power in all four limbs which would not have been possible to assess_ Some of lhe observations contradicted each other with one nurse assessing the patient as 6 on the GCS (2) There was no apparent urgency to secure the prompt attendance of a doctor to assess the_patient: The nursing_staff,_who were described by Sr Snowden as a "junior and end put workforce did not seem to understand the seriousness 0f the injury did not seek senior help from the night team_ The nursing staff did not carry out regular andlor timely neurological observations.

(3) The nursing staff made no contemporaneous notes for a period of hours on the system so there was little information about the timings of their actions. The doctor did not arrive until over two hours laler but did order an urgent CT scan, however when he had the results he then ordered neurological observalions be done every two hours which is not as per hospital protocol
4) The nursing staff on do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett There was no falls planning or prevention, there was no care plan in place on this ward There was no use of items such as sensor crash pads, or equipment which can be attached to patients to warn of movement: The nurse who was stalioned in Ihat 6 bed because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on (he floor.
5) There do not appear to be systems in place at the hospital which are sufficient to recognise when nurses are so inexperienced andlor lacking in (raining that they cannot undertake basic observations on a patient following an injury of this kind.

Responses

1 respondent

The Queen Elizabeth Hospital Kings Lynn NHS Trust NHS / Health Body

24 Apr 2017 PDF

Action Taken

The Queen Elizabeth Hospital King's Lynn NHS Trust has given a copy of the Regulation 28 notice to each nurse on Windsor ward, shared the RCA with senior nurses in A&E, launched a falls campaign, provided training on falls assessment, piloted a new bed rails assessment document, and set up a falls intranet site. It has also devised a training programme for Registered Nurses on the undertaking and interpretation of neurological observations and updated mandatory training days. (AI summary)

View full response

Dear Ms Blake The Regulation 28 report dated 16 March 2017 Concerning the late Mr James Mallett write in capacity as Interim Director of Nursing to respond formally to the Regulation 28 Report: would like to assure you that the matter of in-patient falls within the organisation is taken very seriously and considered regularly at Board level, and by the Non-executive Directors and Governors_ We have an ongoing plan in relation to falls and falls risk in all relevant areas of the Trust and did so at the time of this sad incident involving Mr Mallett but wish to advise that this plan is subject to upgrading, modification and re-appraisal at regular intervals and also at any time when an incident like this prompts re-look commenced in post as our new Medical Director this month and have dlscussed this case with him to ensure learning from this event is shared with the medical teams. A review of the RCA action plan for the fall in question has been undertaken: Further actions taken since this was presented to you at the hearing on 14 March by include the following: A copy of the Regulation 28 notice has been given to each nurse on Windsor and the results of the RCA are being discussed at the ward meeting on Z6th April 2017. A copy of the RCA and Regulation 28 notice has been shared with the senior nurses in A&E to discuss with their respective teams_ A falls campaign was launched on 26th January 2017 and work is on-going with the sisters, charge nurses and matrons to ensure clinical staff are fully aware of the falls assessment process Training is on-going on Windsor ward by the falls co-ordinator on the assessment of patients who may be at risk of falls and falls champions have been identified on the ward. Windsor ward piloted newly devised bed rails assessment document in March
2017. This is to be completed 24 hours and audits are planned to assess compliance at the end of April 2017 and the effectiveness of the tool prior to Trust roll out: The falls intranet site has been set up with all the resources required to support the safe assessment of patients in relation to falls. The new policy for the assessment of patients that require increased observation was ratified in December 2016 and is now in place. This includes clear guidance of how to allocate 1:1 care my every

25 April 2017 The Queen Elizabeth Hospital King's Lynn NHS Trust In relation to the question regarding neurological observations: training programme has been devised for Registered Nurses on the undertaking and interpretation of neurological observations. A pack and the slide presentation (teaching tools) has been shared with the teams in the Emergency division with Trust-wide training that commenced on 1Oth April 2017_ All Registered Nurses in inpatient and access areas will be required to undertake this training programme with a test to demonstrate competence: The Trust has updated the mandatory training days to include clinical scenarios in relation to the care following a fall, and in future this will also be part of induction for new starters and returners (e.g: following maternity leave): hope that this provides you with the detail required, please do not hesitate to contact me if you require anything else_ would be delighted to meet with if you would like to discuss any aspect of nursing care at the Trust:

Report sections

Investigation and inquest

On 24 November 2016 commenced an investigation into the dealh of James Charles MALLETT, 93yrs of age_ The investigation concluded at the of the inquest on 14 March 2017_ The conclusion of the inquest was given in a narrative form (see attached) The medical cause of death was Ia) Subdural Haemorrhage, 1b) Fall and 1c) Parkinson's disease

Circumstances of the death

Mr Mallett was admitled t0 hospital afler a fall at home_ Whilst an inpatient he fell again and sustained a fatal head injury: He was back to bed and a doctor called, this doctor appears to have arrived some two hours later: There was no attempt by the nursing staff to secure his more urgent attendance_ They did not ask for help from the night team: The neurological observations carried out were unclear and not of an acceptable standard or in a-timely manner: In addition when the doctor did arrive he ordered a CT scan (urgent) and after seeing the results showing a massive intracranial bleed; then ordered neurological observations to done two hourly which is not as per hospital guidelines

Action should be taken

In my opinion action should be taken to prevent future dealhs and believe your organisation have (he power t0 take such action

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2017-0075
Date of report: 16 March 2017
Coroner: Yvonne Blake
Coroner area: Norfolk

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: 11 May 2017 (estimated).

Sent to

Queen Elizabeth Hospital NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.