Department of Health
Central Government
Noted
The Department of Health acknowledges the concerns and Pennine Acute Hospitals NHS Trust's review, highlighting actions to improve management, supervision, assessment, and discharge of head injury patients. They note the work of Patient Safety Collaboratives, NICE guidance, and the Falls and Fragility Fracture National Audit Programme. (AI summary)
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From Ben Gummer MP Parliamentary Under Secretary of State (or Care Quality Department Richmond House of Health 79 Whitehall London SWTA ZNS POCS 947712 Tel: 020 7210 4850 Mr M Cox Assistant Coroner 0 3 SEP 2015 HM Coroner s Court The Phoenix Centre LICpl Stephen Shaw MC Heywood OLIO ILR 6 Thank you for your letter of 10h July 2015 following the inquest into the death of Toni Piel. I was very SOrry to hear of Mr Piel's death and wish to extend my sincere condolences to his family. Mr Piel died at his home address on 23rd December 2014. He had earlier fallen at home on 10lh December; suffering a head injury which resulted in an emergency admission to hospital. On that occasion his head wound had been sutured and he had been discharged home with head injury and wound care advice. Your concerns centre round the lack of adequate assessment of the risks to the patient when he was discharged home. You state that: No assessment had been made which would have uncovered that there was no-one at home to observe the patient You refer to NICE guidance issued in January 2014 which recommends home circumstances are taken into account: No assessment of risk factors around discharge was documented in the deceased records These are both operational matters for the trust involved Inote that your report has been sent to the Pennine Acute Hospitals NHS Trust. [understand that Pennine Acute has undertaken a review of this case which has resulted in actions to improve the management; supervision, assessment and discharge ofhead injury patients in their care. The Trust will provide with full details in its response. Way you
Ata national level a network of fifteen Patient Safety Collaboratives, led by Academic Health Sciences Networks, has identified improving discharge from hospital and transfers and transitions of care as a priority. The initial focus of this work is on improving communication during discharge: As the programme of work develops, it is likely that further priorities will be identified Work has also been done by the National Institute of Health and Care Excellence (NICE) to examine the issue of patients who fall in their own homes and the prevention of further falls. This has resulted in the publication of NICE's Quality Standard, 'Falls in older people: assessment after a fall and preventing further falls" in March 2015. The Falls and Fragility Fracture National Audit Programme is a national clinical audit run by the Royal College of Physicians It is designed to audit the care received by hospital patients who are vulnerable to falling or have been injured in a fall, and to facilitate quality improvement initiatives Further information on this programme can be found at: https:/Lwww rcplondon ac uklprojects falls-and-fragility-fracture-audit-programme - 2014 The NICE guideline you reference appears to be Clinical Guidance 176 on Head Injury. This recommends that patients with a head injury should only be discharged when someone is at home to supervise the patient: The section on discharge and follow-up states:
1.9.5 All patients with any degree of head injury should only be transferred to their home if it is certain that there is somebody suitable at home to supervise the patient Discharge patients with no carer at home only if suitable supervision arrangements have been organised, or when the risk of late complications is deemed negligible
1.9.6 Patients admitted after a head injury may be discharged after resolution of all significant symptoms and signs providing they have suitable supervision arrangements at home. NICE guidance is not mandatory. However,practitioners are expected to take such guidance into #ccoint: Iam grateful to you for bringing the circumstances of Mr Piel's death to my attehtion and hope that you findthis reply helpful. Hb~ BEN GUMMER fffap- fully
Ata national level a network of fifteen Patient Safety Collaboratives, led by Academic Health Sciences Networks, has identified improving discharge from hospital and transfers and transitions of care as a priority. The initial focus of this work is on improving communication during discharge: As the programme of work develops, it is likely that further priorities will be identified Work has also been done by the National Institute of Health and Care Excellence (NICE) to examine the issue of patients who fall in their own homes and the prevention of further falls. This has resulted in the publication of NICE's Quality Standard, 'Falls in older people: assessment after a fall and preventing further falls" in March 2015. The Falls and Fragility Fracture National Audit Programme is a national clinical audit run by the Royal College of Physicians It is designed to audit the care received by hospital patients who are vulnerable to falling or have been injured in a fall, and to facilitate quality improvement initiatives Further information on this programme can be found at: https:/Lwww rcplondon ac uklprojects falls-and-fragility-fracture-audit-programme - 2014 The NICE guideline you reference appears to be Clinical Guidance 176 on Head Injury. This recommends that patients with a head injury should only be discharged when someone is at home to supervise the patient: The section on discharge and follow-up states:
1.9.5 All patients with any degree of head injury should only be transferred to their home if it is certain that there is somebody suitable at home to supervise the patient Discharge patients with no carer at home only if suitable supervision arrangements have been organised, or when the risk of late complications is deemed negligible
1.9.6 Patients admitted after a head injury may be discharged after resolution of all significant symptoms and signs providing they have suitable supervision arrangements at home. NICE guidance is not mandatory. However,practitioners are expected to take such guidance into #ccoint: Iam grateful to you for bringing the circumstances of Mr Piel's death to my attehtion and hope that you findthis reply helpful. Hb~ BEN GUMMER fffap- fully