Mollie Bentham

Coroner's concerns

AI summary

Repeated family concerns about abdominal pain and rising infection markers were not documented, escalated to medical teams, or examined, leading to a significant delay in diagnosing a critical condition.

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the medical notes: The concerns were not brought to the attention of the medical team and no examination by the medical team was conducted in relation to the family concerns:
4. On the 24t April 2015 Miss Bentham had a medical review which showed that her CRP, which is a marker of infection, had risen to 178 and her white cell count; also sign of infection, had risen. There was a documented discussion with the family at 17.00 hours on the 24th April 2015 when the family, once again, mentioned the abdominal but the was not referred to in the documented note of the meeting: Prior to the meeting with the family at 17.00 hours on the 24th April 2015 Professor Baker , Consultant Geriatrician, had reviewed Miss Bentham at 10.30 hours on the same but the review by Professor Baker made no mention of abdominal pain and the previous concerns of abdominal pain mentioned by the family were not brought to the attention of Professor Baker , Miss Bentham was not sufficiently communicative to bring the to the attention of Professor Baker and the plan noted by Professor Baker at 10.30 hours on the 24th April 2015 did not refer to abdominal pain or any examination in relation thereto.
5. On the 26th April 2015 a Healthcare Assistant noted that Miss Bentham had a hard area to the left side of her abdomen and complained of The Healthcare Assistant informed the nursing staff of finding and Miss Bentham was given morphine sulphate in relation to the pain_ The 26t April 2015 was a Saturday and over the same weekend Miss Bentham was visited by two on call doctors, including an of hours General Practitioner but the doctors did not make a note of their attendance: A note was made in the nursing notes that the out of hours General Practitioner was called by the nursing staff as there was a hard mass to the left side of Miss Bentham's abdomen and her score had increased:
6. The Matron for Darley Court Intermediate Care Centre gave evidence that a doctor based at the Centre would be present at the Centre on a Monday to Friday from 9.OOam to 5.0Opm and on a Saturday and Sunday from 9.00am to 1.0Opm. Outside those hours a request for a medical review must be addressed to the out of hours GP service: The out of hours GP service will conduct an initial triage and a General Practitioner will attend subject to appropriate triage: 7 _ On the 27t April 2015, which was a Monday, Miss Bentham was reviewed by] who is a member of the medical team based at Darley Court Intermediate Care Centre; did not make a note of the attendance and there was no note that the attendance of the out of hours General Practitioner over the weekend and Miss Bentham's abdominal pain were brought to attention: 8, On the 27th April 2015 a Multi-Disciplinary Team Meeting was held and Miss Bentham was discussed at the Meeting_The note of the Meeting pain pain day pain pain. her out pain did not refer to those present at the Meeting nor in relation to any action to be taken or the persons to take any action: The note of the Multi-Disciplinary Team Meeting simply noted fast track paperwork and the fact that Miss Bentham had been accepted at Rivington View Nursing Home: 9_ On the 28th April 2015 a medical review identified that the abdomen was found to be tender but not in one specific place and the abdomen was described as soft, meaning no rigidity as would be expected with peritonitis; In view of the fact the patient had been constipated for some six days prior to the 28th April 2015 laxatives were prescribed as well as all previously prescribed medications:
10.On the April 2015 Miss Bentham was transferred to Rivington View Nursing Home, Albert Street; Horwich, Bolton where she deteriorated and died on the 1st 2015

Responses

1 respondent

Mollie Bentham

17 Feb 2016 PDF

Action Taken

Bolton NHS Foundation Trust has recruited a permanent doctor for Darley Court, improved out-of-hours GP access, and developed new Standard Operating Procedures for handover. They have also implemented new weekly and monthly documentation training and audits, and the daily safety huddle now includes medical and therapy teams. A task group is reviewing MDT meetings, with work expected to complete by March 2016. (AI summary)

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Dear Mr Walsh

Re: Mollie Bentham - Deceased

Re: Regulation 28 Report to Prevent Future Deaths

I am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued following the Inquest into the death of Mollie Bentham held on 14 December 2015. May I take this opportunity to extend my sincere condolences to the family of Mrs Bentham for their loss.

On receipt of the Regulation 28, I requested that Matron for Darley Court, and Professor Consultant Geriatrician review the matters detailed in your report and I am now in a position to respond to your concerns outlined in the Report.

In addition, the Trust has also reviewed the levels of medical cover that were being provided at Darley Court and have made improvements that will benefit patient care.

The Trust recently recruited a permanent doctor to Darley Court Intermediate Care (IMC) on a full time basis and this doctor is now in post. Prior to the commencement o the medical cover had been provided by locum doctors on long term contracts. I believe this permanent arrangement will enhance communication between the medical and nursing teams and provide continuity of care for patients. The level of consultant cover has also been reviewed and it is planned to increase the number of sessions a consultant will attend Darley Court IMC from the current provision of two sessions per week.

The Darley Court staff now have direct access to an Out of Hours (OOH) General Practitioner (GP) who is attached to the Admission Avoidance Team (AAT). The GP is with the AAT from 18:30 to 22:00 Monday to Friday and 9:00 to 22:00on Saturday and Sunday. Patients that require urgent medical attention outside of the hours of medical cover by the doctor at Darley Court but within the hours stipulated above will be seen by the OOH GP based at the AAT. It has been agreed with BARDOC (OOH GP Provider) that the GP will document details of the consultation in the medical notes at Darley Court. This will ensure that both the nursing and medical staff are informed of the treatment plan for the patient. I understand that this service has been utilised and positive feedback has been received from staff at Darley Court. For medical attention outside the hours outlined above, the OOH GP service will be contacted directly.

Since coming into post Matron has undertaken significant pieces of work to improve the standard of documentation and handover at Darley Court. This has included the adoption of the

'SAFER' bundle was introduced in May 2015 and updated in September 2015. The SAFER care bundle is a set of rules that will improve timely assessments and patient flow. The concept for Darley Court involves:

* Senior Review - of the patient.
* Assessment - setting standards for timely Multi-Disciplinary Team (MDT) assessments.
* Flow - setting a proposed daily number of patients being discharged /stepped down to other units, processing of referral standards.
* Early Discharge - identification of patients who may be supported for an early discharge to other services, setting an agreed discharge date and ensure the discharge is safe.
* Regular Review - setting standards for MDT review.

Matron has reminded all staff that any concerns raised regarding a patient need to be clearly documented in the patient's ongoing records and escalated where appropriate. A copy of the NMC guidelines has been circulated to all nursing staff highlighting the importance of accurate record keeping. Escalation guidance has also been produced to be read in conjunction with National Early Warning Score (NEWS) guidance.

Documentation training is also now included in the new weekly training programme, furthermore additional training is being provided on a monthly basis in respect of documentation and record keeping. Monthly documentation audits are now being undertaken to ensure compliance with this action and ensure the quality of record keeping is improved.

Standard Operating Procedures (SOP) have been developed with regard to improving the handover of information. The Daily Safety Huddle which takes place every morning now includes the doctor and a senior member of the therapy team. In addition, the senior Sister at Darley Court has been reviewing the efficiency of the handover process at the end of and commencement of a shift. Where further improvements are identified these will be included in the SOP for handovers.

A review of the conduct of MDT meetings including evaluation of the paperwork used at the meetings has been lead by Ann Lloyd, Consultant Nurse for Older People. has set up a task and finish group and taken steps to address the issues of poor documentation and failure to follow up actions identified at MDT meetings. I am advised this work is still ongoing however its purpose will be to ensure there is improved clinical decision making from all disciplines attending the MDT with appropriate timescales set for actions to be taken and completed, ultimately this will facilitate the safe discharge of our patients. It is expected that this work will be complete by 31 March 2016.

I do hope that my response has provided you with the assurance that you and the family are looking for. If you can need any further information, or if I can be of any further assistance please do not hesitate to contact me.

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Circumstances of the death

Mollie Bentham died at Rivington View Nursing Home; Albert Street, Horwich; Bolton on the 1s May 2015. On the 12th February 2015 Miss Bentham was admitted to the Royal Bolton Hospital, Bolton with lower respiratory tract infection and acute on chronic kidney disease: She suffered with confusion due to delirium and she had episodes of seizures: Following treatment at the Hospital Miss Bentham was transferred to Darley Court Intermediate Care Centre, Shepherd Cross Street; Bolton on the 6th March 2015 where she received further treatment; including treatment for Norovirus infection_ 3_ Prior to 23r April 2015 plans were being considered for Miss Bentham's discharge from Darley Court to a Nursing Home On the 23rd April 2015 the family of Miss Bentham had noticed that Miss Bentham was suffering with some abdominal pain and the family reported the abdominal to nursing staff at Darley Court However 27th the pain the concerns Of the family were not recorded in the nursing notes nor in the medical notes: The concerns were not brought to the attention of the medical team and no examination by the medical team was conducted in relation to the family concerns:
4. On the 24t April 2015 Miss Bentham had a medical review which showed that her CRP, which is a marker of infection, had risen to 178 and her white cell count; also sign of infection, had risen. There was a documented discussion with the family at 17.00 hours on the 24th April 2015 when the family, once again, mentioned the abdominal but the was not referred to in the documented note of the meeting: Prior to the meeting with the family at 17.00 hours on the 24th April 2015 Professor Baker , Consultant Geriatrician, had reviewed Miss Bentham at 10.30 hours on the same but the review by Professor Baker made no mention of abdominal pain and the previous concerns of abdominal pain mentioned by the family were not brought to the attention of Professor Baker , Miss Bentham was not sufficiently communicative to bring the to the attention of Professor Baker and the plan noted by Professor Baker at 10.30 hours on the 24th April 2015 did not refer to abdominal pain or any examination in relation thereto.
5. On the 26th April 2015 a Healthcare Assistant noted that Miss Bentham had a hard area to the left side of her abdomen and complained of The Healthcare Assistant informed the nursing staff of finding and Miss Bentham was given morphine sulphate in relation to the pain_ The 26t April 2015 was a Saturday and over the same weekend Miss Bentham was visited by two on call doctors, including an of hours General Practitioner but the doctors did not make a note of their attendance: A note was made in the nursing notes that the out of hours General Practitioner was called by the nursing staff as there was a hard mass to the left side of Miss Bentham's abdomen and her score had increased:
6. The Matron for Darley Court Intermediate Care Centre gave evidence that a doctor based at the Centre would be present at the Centre on a Monday to Friday from 9.OOam to 5.0Opm and on a Saturday and Sunday from 9.00am to 1.0Opm. Outside those hours a request for a medical review must be addressed to the out of hours GP service: The out of hours GP service will conduct an initial triage and a General Practitioner will attend subject to appropriate triage: 7 _ On the 27t April 2015, which was a Monday, Miss Bentham was reviewed by] who is a member of the medical team based at Darley Court Intermediate Care Centre; did not make a note of the attendance and there was no note that the attendance of the out of hours General Practitioner over the weekend and Miss Bentham's abdominal pain were brought to attention: 8, On the 27th April 2015 a Multi-Disciplinary Team Meeting was held and Miss Bentham was discussed at the Meeting_The note of the Meeting pain pain day pain pain. her out pain did not refer to those present at the Meeting nor in relation to any action to be taken or the persons to take any action: The note of the Multi-Disciplinary Team Meeting simply noted fast track paperwork and the fact that Miss Bentham had been accepted at Rivington View Nursing Home: 9_ On the 28th April 2015 a medical review identified that the abdomen was found to be tender but not in one specific place and the abdomen was described as soft, meaning no rigidity as would be expected with peritonitis; In view of the fact the patient had been constipated for some six days prior to the 28th April 2015 laxatives were prescribed as well as all previously prescribed medications:
10.On the April 2015 Miss Bentham was transferred to Rivington View Nursing Home, Albert Street; Horwich, Bolton where she deteriorated and died on the 1st

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