Source · Prevention of Future Deaths

David Cooper

Ref: 2016-0459 Date: 21 Dec 2016 Coroner: Andrew Barkley Area: South Wales Central Responses identified: 1 / 2 View PDF

Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack of 'joined-up' thinking and insufficient systems for booking one-to-one care for high-risk patients.

Date 21 Dec 2016

56-day deadline 9 Apr 2017 est.

Responses identified 1 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

[BRIEF SUMMARY OF MATTERS OF CONCERN] When transfers between wards took place,the evidence revealed that there was my a lack of comprehensive hand-over by the transferring ward to the receiving especially in terms of identifying the patient's risk of falls. For example, on 18 Mr Cooper was in receipt of 1.1 nursing care, but on transfer t0 ward not only was that never given, but the evidence suggested it was not considered accuracy and completeness of nursing notes and records left much to be desired. For example, on Ward 21 when he fell three times, there was no entry made in the Falls a document which was supposed to act as a tool for nursing staff to assess whether there was & pattern t0 the numerous falls sustained save for the last fall on 5th March This deprived staff of the opportunity to see the "whole picture" and to take into consideration the eight falls which he had sustained up to that 3, The evidence revealed that there was a distinct Iack of "joined up" thinking and a failure to see the "whole picture' Mr Cooper's risk of falling was as high when he was admitted in October 2015 as it was when he died in March 2016, but still he sustained 9 falls As with many other cases involving patients at high risk of falls, the evidence revealed shortcomings in the system used for booking additional staff to provide "1:1" care, revealing a system which left front line nursing staff unable to cope with the challenges in looking after the most vulnerable_

Responses

1 respondent

University Health Board NHS / Health Body

14 Feb 2017 PDF

Action Taken

The University Health Board established a Falls Management Group, reviewed policies and training requirements, introduced National Patient Safety Agency's Risk Assessments, devolved falls management to Directly Managed Units, and will continue to meet as a scrutiny panel with a Consultant Physician leading the group. (AI summary)

View full response

Dear Mr Barkley, Re: David Bassett Cooper Inpatient at Princess of_Wales_HospitalBridgend_CF3L IRQ write further to the Regulation 28 Report to Prevent Future Deaths in relation to Mr David Bassett Cooper, received by Abertawe Bro Morgannwg Health Board from your department in December 2016. have enclosed an Action Plan completed by Princess of Wales Directly Managed Unit and Mental Health Learning Disability Unit in relation to the four points highlighted in your report: hope the enclosed Action Plan demonstrates the actions that have, and will continue to be taken, in relation to these issues and provides you the level of assurance that is required_ The Health Board established Falls Management Group in September 2015. This was a task and finish group that reviewed policies and training requirements in relation to falls management: The Health Board introduced the National Patient Safety Agency s Risk Assessments ad enclose the Health Board's Falls Policy and other supporting information for your review: The Falls Management Group last met in December 2016 and devolved falls management to the Directly Managed Units to ensure clinical orientation and responsibility: The Falls Management Group will continue to meet as a scrutiny panel to ensure that appropriate training and individual falls_scrutiny is being undertaken with continued review of performance data Consultant Physician and Geriatrician, will be leading the Falls Management Group. Bwrdd lechyd ABM Yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Abertawe Bro Morgannwg ABM University Health Board is the operational name of Abertawe Bro Morgannwg University Local Health Board Pencadlys ABM ABM Headquarters, Talbot Gateway, Port Talbot, SA12 7BR. Ffon Tel: (01639) 683344 www abm university-trustwales nhs.uk along

If you require any further information in relation to the information contained in the Action please do not hesitate to contact me.

Report sections

Investigation and inquest

On 6"h April 2016 commenced an investigation into the death of David Bassett COOPER aged 81. The investigation concluded at the end of the inquest; with a jury, on 15"h December 2016. The conclusion of the inquest jury was that of a narrative conclusion and the medical cause of death was recorded as Ia, Acute on chronic subdural haematoma (traumatic) 1b Recurrent Falls 2. Hospital Acquired Pneumonia The narrative conclusion was "following a fall as an inpatient, Mr Cooper died of a traumatic brain injury , t0 which failure(s) in medical nursing care contributed"

Circumstances of the death

Mr COOPER suffered a traumatic head injury as a result of a road trafific collision in 1992 , from which he recovered, and suffered a stroke in January 2009. He fell in the community and sustained a serious head injury on 12th October 2015 and was admitted to the Princes of Wales Hospital in Bridgend. Whilst in hospital, he was transferred between several wards and up to the time of his death , he suffered 9 separate falls. The final fall on 5th March 2016 caused a subdural haematoma from which he died

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2016-0459
Date of report: 21 December 2016
Coroner: Andrew Barkley
Coroner area: South Wales Central

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Apr 2017 (estimated).

Sent to

Swansea Bay University Health Board

Welsh Assembly Government

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.