Source · Prevention of Future Deaths

Christine Street

Ref: 2016-0177 Date: 10 May 2016 Coroner: Veronica Hamilton-Deeley Area: Brighton and Hove Responses identified: 1 / 1 View PDF

Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to an unwitnessed fall. There was also a complete lack of documentation for specialling observations, contravening Trust and national policies.

Date 10 May 2016
56-day deadline 5 Jul 2016 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to an unwitnessed fall. There was also a complete lack of documentation for specialling observations, contravening Trust and national policies.
View full coroner's concerns
(1) Documentation with regard to the admission document (which was not completed) and the doctors pro forma to document the fall on the 11th September 2015 (was not completed). The lack of these documents did not affect the outcome, but it is bad practice that they were not completed and placed with Mrs_ Street's notes.

(2) Mrs. Street was being specialled: She was on arm's length observations and had been since just after her biopsy on the 28"h August 2015. These observations had apparently been carried out successfully over the following days until early on the morning of the 11 September when an experienced HCA was specialling her: It was clear that he knew exactly how he should be speciailing her, it was clear that the handover to on 10"" September had been effective_ It comprised a general handover; a bedside handover and a handover sheet The handover sheet was flawed since it suggested that Mrs. Street had, had a fall already on the 9 September. There was no evidence to suggest that this was in fact the case. For some reason on the occasion when he escorted Mrs. Street to the toilet; a few steps from her bed in 9 on Level 8a West and indeed a few steps from the nurses station because bay 9 is a high dependency he left her in the toilet, closed the door and did not wait outside. A few moments later she had an unwitnessed fall, the nurse at the nursing station heard the noise and rushed in to find her on the floor with a head injury which was immediately obvious. He looked after her and she was taken by wheelchair back to her bed once it had been established that she did not appear to have any injury other than the head injury. Thereafter on the 11 she was appropriately managed_ The Trust policy on observations for patients with mental health illness (this lady was deemed not to have mental capacity due to the extent of the symptoms produced by the brain tumour and was the subject of a Deprivation of Liberty Safeguarding Order put in place urgently on the 318 August 2015) was not adhered to by the HCA The Trust policy on observations includes good paperwork for specialling including a specialling document which will stay with the care plan and daily documentation as to the specialling, plus an observation sheet Apart from one or two observation sheets which appear to have been done on the 31st August; there was absolutely no documentation at all. This was in direct contravention of the Trust's own policy and indeed of the NICE guidance on observations,Le the national policy him the bay bay,

VERONICA HAMILTON-DEELEY, LLB.

Responses

1 respondent
Brighton and Sussex University Hospitals NHS Trust NHS / Health Body
6 May 2016 PDF
Action Taken

Brighton and Sussex University Hospitals NHS Trust held study days for nurses on LBAW covering topics including Deprivation of Liberty, falls prevention, one-to-one care, and end of life care, after the inquest. An audit has been carried out of every patient specialled and the findings are being collated for action. (AI summary)

View full response
Dear Miss Hamilton-Deeley The Late Christine Street date of birth 31.03.1944 NHS No: 418 862 7476 Thank you for your letter of 6 May 2016_ and for drawing your concerns to the attention of the Chief Executive. As is currently away from the Trust, she has asked that respond to you on her behalf . am aware that the Chief Executive acknowledged that the care provided to Mrs Street was unacceptable, and indeed wrote to the family shortly after her arrival at the Trust early in April 2016, to apologise about this before the inquest took place. She and both believe it is vital that the Trust staff really learn from experience when something has gone wrong: am aware that the quality of documentation for Mrs Street was poor in several respects and this has been followed up with both nursing and medical staff _ The staff had recognised that Mrs Street was at high risk of falls, and had intended her to have constant attention knowing that she lacked capacity to comprehend her risk of falling as a result of the tumour_ It appears that the ward nurses had mistakenly thought that the 'care record for patient requiring specialling' which was available as an appendix to the Trust's policy for the observation of adult patients with mental health problems was not intended for use when caring for a patient who was suffering not from a mental illness but from specific neurological condition in this instance, a brain tumour Rapid action was taken when this came to light, to correct their understanding_ A series of study days has been held for the nurses on LBAW to help them understand fully their responsibilities and obligations Topics addressed have included Deprivation of Liberty; falls prevention and management; one to one care; end of life care; and documentation. A practice educator took up post on the ward earlier this year who provides training both on specific neuro-competencies for nurses and also on more general nursing skills. It is particularly disappointing that Mrs Street was injured in fall as this Trust has worked very hard indeed over several years to implement an active falls prevention programme. As a result the Trust has one of the lowest rates of inpatient falls of any acute Trust in the country. Nevertheless, in her weekly messtgeutoatnstaff , the Chief Executive has brighton ahd sussex NHS Postgraduate Deanery for Kent medical school KSS Sussex and Your ref:

reminded all staff of the scope for further improvement, as well as taking the opportunity to remind us all of the actions to be taken should someone fall. Following receipt of your letter she has also used her weekly message to remind staff to make sure they are familiar with the Trust policy on observation of patients mentioned above, as well as to use the adult care pathway for people requiring one to one care, acting on the prompts contained within it and documenting these actions comprehensively and contemporaneously. Since Mrs Street's fall; more work has been done to ensure the bank staff are well-informed about the policy for the observation of adult patients with mental health problems, and the associated documentation to be used if are asked to provide one to one care for patient: Teaching sessions have also been run for the Trust'$ health care assistants, to refresh their knowledge about what is required when are asked to provide one to one care to any patient: Furthermore an audit has been carried out very recently of every patient specialled The findings are now being collated and action will be taken, including if necessary revision of the current policy, in the light of any learning points that emerge from this audit: In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit: Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records_ Learning from these sad events is not limited to the Directorate of Neurosciences and Stroke Services. The Directorate Lead Nurse gave a formal presentation to her fellow senior nurses from across the whole Trust, after the inquest, to disseminate the lessons to be learned as widely as possible_ Thank you once again for raising your concerns with the Trust.

Report sections

Investigation and inquest
On 14th September 2015 commenced an investigation into the death of Mrs. Christine Street The investigation concluded at the end of the inquest on 29"h April 2016.The conclusion of the inquest was NARRATIVE CONCLUSION_ Following admission to hospital on 22nd August 2015, Mrs_ Christine Valerie STREET was diagnosed with an aggressive brain tumour: Her symptoms were disorientation, confusion and a generalised left-sided weakness affecting capacity to mobilise and leaving her prone to falling: This left her in need of continuous one-to-one care and assistance when mobilising: Due to her lack of mental capacity and attempts to leave the hospital, Mrs. STREET was subject to a Deprivation of Liberty Safeguarding Order. and and

VERONICA HAMILTON-DEELEY, LLB.
Circumstances of the death
See Record of Inquest
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.
Copies sent to
End of Life Care Facilitator

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Report details

Reference
2016-0177
Date of report
10 May 2016
Coroner
Veronica Hamilton-Deeley
Coroner area
Brighton and Hove

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: 5 Jul 2016 (estimated).

Sent to

Brighton and Sussex University Hospitals NHS Trust

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