Source · Prevention of Future Deaths

Ruth Smith

Date: 15 Dec 2015 Coroner: Mary Burke Area: West Yorkshire (West) Responses identified: 1 / 1 View PDF

There were significant delays in doctor review, inadequate nursing observations, and poor record-keeping by both nursing and medical staff. Crucial follow-up for medical interventions was also absent.

Date 15 Dec 2015

56-day deadline 9 Feb 2016

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Nursing Care

At 22.05 Mrs Smith was found to have an elevated MEWS score and as a result a request was made for an FY 1 Doctor to review. Evidence was given by a senior charge nurse( who provided an overview of nursing care to Mrs Smith, but who was not directly involved in her care) that following this Mrs Smith should have undergone hourly observations. This did not happen. There was reference to observations being undertaken at 00.30 but these were not recorded. Further observations were incomplete The FY1 Doctor did not attend the ward until 00.30. There was no record within the notes to suggest that enquiries were undertaken between 22.30 and 00.30 to chase up the attendance of the FY 1 Doctor.

I have the following concerns:

1. No attempts were made to ensure a doctor attended and reviewed Mrs. Smith between 22.30 and 00.30.
2. The level of nursing monitoring (hourly observations) taking place for much of the period between 22.30 on the 15th April and 03.25 on the 16th April.
3. The standard of the nursing record keeping.

On the 16th April a red incident incident investigation was undertaken but none of the above matters were included in the report although I heard evidence from one of the authors of the report that “a number of issues” had been identified and fed back to the Legal Services department. I received no written communication of this, nor whether any steps or measures had been implemented as a result, hence the reason why I am making this report.

Medical Care

A doctor attended at 18.40 upon Mrs Smith but did not make a full record within the medical records.

Nursing staff requested a doctor review at 22.30 hours. No doctor attended until 00.30 hours.

When a doctor did attend a fluid challenge was implemented. The doctor did not return to review Mrs Smith or put in place arrangements for another doctor to review. At 2.00 hours an FY2 doctor attended following a request by nursing staff. The FY2 doctor determined that Mrs Smith’s bloods and blood gases should be checked. I heard evidence that nursing staff advised the FY2 doctor that Mrs Smith needed more senior medical review by a registrar. The FY2 made no entries within Mrs Smith’s medical records.

I have the following concerns:

1. The 2 hour time lapse between a request for a doctor review and a doctor attending upon Mrs.Smith.
2. No review was put in place following the implementation of the fluid challenge.
3. The standard of record keeping and lack of records being made by the doctors who attended up Mrs. Smith on the evening of the 15th April and early hours of the 16th April up until the Registrar’s involvement at 03.25 a.m. on the 16th April.

Responses

1 respondent

Ruth Smith

23 Mar 2016 PDF

Noted

Calderdale and Huddersfield NHS Foundation Trust clarifies its existing systems, including 'Nerve Centre' for electronic patient observations with automatic escalation for elevated NEWS scores, and daily 'Safety Huddles' where ward staff discuss patient care. The response focuses on explaining current practices rather than describing new actions taken or planned. (AI summary)

View full response

Dear Ms Burke

Re: Regulation 28 – Ruth Hilda Smith

Thank you for your letter dated 23 March 2016.

I have made enquiries with our clinical team and can respectfully clarify in the order raised:

1. "Nerve Centre" – Nerve Centre is the use of mobile electronic observations and hospital at night software to improve patient safety and staff communication anywhere within our hospitals 24 hours a day, 7 days a week. All patient observations are recorded on an IPAD. The use of mobile technology also allows doctors and nurses to have all the tools and information at hand to be able to respond rapidly and effectively to deteriorating patients.

If a patient's National Early Warning Score (NEWS) goes above 3 it immediately triggers an escalation to the nurse in charge for action. They then deal with the escalation or request help from the medical team. The parameters for acceptable observations are pre-set by Medical staff.

"Nerve Centre Trigger" If the NEWS score is higher then the IPAD immediately triggers directly to Critical Care Outreach and Medical staff for action. Thus the raised NEWS score can be determined as a nerve centre trigger.

"Nerve Centre Data" The data for every patient for every observation is stored on a central database. This information can be accessed by the ward manager to look at trends. For instance timely responses to elevated NEWS scores.

Chairman: Andrew Haigh Chief Executive: Owen Williams Page 1

2. Daily Safety Huddles

Safety huddles are a key part of the safety culture on wards which are used to help reduce patient harm and improve patient care. The safety huddles are daily focussed frontline team discussions of specific patients led by clinicians. Use of safety huddles are encouraged by the Improvement Academy as evidence shows that teams using huddles as part of their ward routine have reduced harm in their area. After the Doctor's ward round in a morning all ward staff meet up to discuss changes to patients. Her care is planned with an emphasis on prioritising care for the acutely ill patients. This is termed a safety huddle. These can also happen at other times throughout the day if deemed necessary by the nurse in charge.

The safety huddles are in addition to routine nursing handover which is still given at the start of each shift to the nurses coming on duty.

I hope that they provide the clarification required.

Report sections

Investigation and inquest

On the 22nd April 2014 an investigation was opened into the death of Ruth Hilda Smith and an inquest was concluded on the 14th October 2015. The conclusion of the inquest was a narrative:

Ruth Hilda Smith died on 16 April 2014 on Ward 3, Huddersfield Royal Infirmary due to a haemothorax which occurred as a result of the necessary insertion of a central venous access line required to facilitate treatment of her underlying condition.

The cause of death was established as: 1(a) Haemothorax 1(b) Central line insertion
11. Sepsis, altered liver function and pneumonia.

Circumstances of the death

Mrs Smith had a medical history of peripheral vascular disease, chronic kidney disease, chronic obstructive pulmonary disease, hypothyroidism and hiatus hernia. In May 2013 she had been diagnosed with colon cancer and underwent a colectomy with ileostomy in June 2013. Mrs Smith experienced a difficult post operative period, developing significant wound infection and high stoma output. She was eventually discharged from hospital but had 3 more hospital admissions between September 2013 and December 2013, for recurrent problems of high stoma output and acute kidney symptoms. Mrs Smith was readmitted to Calderdale Royal Hospital again on the 28th December 2013 with problems with her stoma. During this admission she was noted to have symptoms of necrosis and leg rest pain and as a result Mrs Smith was transferred to Huddersfield Royal Infirmary under the care of the vascular team. Investigations were undertaken which revealed that she had bilateral common iliac occlusion for which she underwent an elective vascular procedure on the 24th February 2014. Following a period in intensive care Mrs Smith’s condition appeared to stabalise, however her condition subsequently began to deteriorate, she developed poor urine output and respiratory symptoms and showed signs of sepsis. Mrs Smith also developed severe abdominal pain an MRCP revealed ascites and generalized oedema. Mrs Smith’s treating clinicians were endeavouring to provide her with full medical support but difficulties were encountered in cannulating her so as to ensure she received intravenous antibiotics and fluid support. As a result a decision was taken for Mrs Smith to have a central venous line inserted. This was undertaken on the 15th April 2014. The procedure was uneventful and a check chest x-ray revealed that the central venous access was in the correct position. During the early evening Mrs Smith’s condition began to steadily deteriorate. She was reviewed by a number of doctors and nursing staff, culminating in being reviewed by a Registrar at 3.25 now the 16th April, who confirmed that Mrs Smith appeared to be pre-moribund and advised her family that no direct intervention was likely to resolve Mrs Smith’s presentation. Mrs Smith died a few hours later, her death being confirmed at 6.30 hours on 16th April 2014. Mrs Smith subsequently underwent a post-mortem examination by , who concluded that the medical cause of Mrs Smith’s death was due to 1(a) Haemothorax due to 1(b) central line insertion and 2. sepsis altered liver function and pneumonia.

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Shared signals

Related inquiry recommendations

Report details

Date of report: 15 December 2015
Coroner: Mary Burke
Coroner area: West Yorkshire (West)

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: 9 Feb 2016.

Sent to

Calderdale and Huddersfield NHS Foundation Trust

Source links

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Data: judiciary.uk.

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