Source · Prevention of Future Deaths

Edwina Moses

Ref: 2016-0462 Date: 22 Dec 2016 Coroner: Andrew Barkley Area: South Wales Central 1 response identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner identified a poor system for requesting and securing additional nursing cover for one-to-one patient support, leading to staff confusion and frequent unavailability of help. This raised concerns about staffing levels and staff capacity to safely care for patients.

Date 22 Dec 2016

56-day deadline 16 Feb 2017 est. estimated from the report date

Responses identified 1 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner identified a poor system for requesting and securing additional nursing cover for one-to-one patient support, leading to staff confusion and frequent unavailability of help. This raised concerns about staffing levels and staff capacity to safely care for patients.

View full coroner's concerns

_ The evidence revealed that there was a poor System in place for requesting aged day: The additional nursing cover t0 provide one t0 one support. There was confusion by front line staff as to who was responsible for identifying, booking and ensuring that such help was provided_ 2, The evidence showed that it was common place for additional nursing cover not to attend and staff were then left to provide one to one cover alongside their main stream duties which was wholly unrealistic Given the apparent frequence in which additional nursing cover is "unavailable' often in the context of dealing with patients suffering with dementia, the issue of appropriate staffing levels on wards and the of staff to safely Iook after patients must be a concern;

Responses

1 respondent

University Health Board

NHS / Health Body

Indexed date: 14 Feb 2017 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Princess of Wales Hospital Managed Unit reviewed its process for enhanced observation, including the standard of completion of risk assessments. • A process to monitor staffing levels across the site, including the identification of patients requiring enhanced observation, has been introduced. • An audit process was introduced in February 2017 to monitor adherence to the Increased Nursing Observation Guidelines.

View full response

Dear Mr Barkley, Re: Edwina Rose Moses Inpatient at Princess of Wales Hospital_Bridgend_CF3L 1RQ write further to the Regulation 28 Report to Prevent Future Deaths in relation to Mrs_ Edwina Rose Moses 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 in relation to the two points highlighted in your report: 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 Princess of Wales Hospital Managed Unit has reviewed its process around enhanced observation_ The review included the standard of completion of Risk Assessments and introducing a process to monitor staffing levels across the site which will include the identification of all patients requiring enhanced observation: There is daily monitoring of staffing levels in place which is subsequently handed over to the Out of Hours team for evenings and weekends: All staff have been made aware of the process to check the Nurse Bank system. This work will link into the Health Board Falls Management group as prevention of falls is one of the main criteria for requesting enhanced observation: An audit process has been introduced across the Princess of Wales Hospital Managed Unit in February 2017 to monitor adherence to the all elements f the Increased Nursing Observation Guidelines_ 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_ Tel: (01639) 683344 wabm university-trust wales nhs.uk hope Ffon

If you require any further information in relation to the information contained in the Action Plan, please do not hesitate t0 contact me.

Report sections

Investigation and inquest

On the 23r September 2016 commenced an investigation into the death of Edwina Rose Moses The investigation was concluded at an end of an inquest dated the 20lh December. The conclusion of the inquest was that of a narrative conclusion namely "Edwina Rose Moses, who suffered from complex health issues and dementia died as a result of an upper gastrointestinal bleed having undergone surgery to repair two broken hips after a fall at her home address and a fall in hospital at a time when she was assessed as requiring one t0 one care

Circumstances of the death

The deceased was admitted to hospital on the 15" August having fallen at her home address fracturing her left neck of femur. That was surgically repaired on the 18in August after which; despite some setbacks in terms of respiratory function, she appeared to be making a recovery: She fell from her hospital bed on the 318 August at a time when she should have been receiving one to one nursing care. She fractured her right hip which was surgically repaired the same In the following days she became increasingly unwell showing signs of a gastrointestinal bleed and deteriorated and passed away on the 19h September 2016

Action should be taken

In my opinion action should be taken t0 prevent future deaths and believe you and your organisation have the power t0 take such action.

Similar PFD reports

Shared signals

Report details

Reference: 2016-0462
Date of report: 22 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: 16 Feb 2017 (estimated from the report date).

Sent to

ABMU Health Board

Welsh Assembly Government

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.