Source · Prevention of Future Deaths

Philip Robinson

Ref: 2015-0225 Date: 13 Mar 2015 Coroner: Elizabeth Didcock Area: Nottinghamshire Responses identified: 1 / 1 View PDF

Unclear ECG guidelines for breathlessness, unsatisfactory safe discharge audits, and inadequate communication of Early Warning Scores (EWS) are significant concerns. Delays in digital system implementation and the extreme risk of absent senior medical review compound these issues.

Date 13 Mar 2015

56-day deadline 8 May 2015 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

 The results from audits of compliance with safe discharge arrangements using a discharge stamp, including the recording of the Early Warning Score on discharge are unsatisfactory  The improved recording and communication of the EWS from Health Care assistant, to Nurse, to doctor as necessary, is not evident throughout the Hospital  The medical staff involved in this Inquest do not agree with the SUI author, that an ECG was indicated during Mr Robinson’s admission. There are no clear guidelines to assist medical staff with this clinical decision making when a patient presents with acute breathlessness. An audit to monitor the threshold for performing an ECG has shown this is still not reliably performed when clinically indicated  The risk of there being no one available to provide senior medical review when a registrar is absent remains an ‘extreme risk’  The iHospital which undoubtedly will assist in improving EWS recording, is not yet in place. Implementation is planned for June 2015, and there is potential for delay. Interim plans for a ‘At a glance Board’ are not clear, with confusion as to where the EWS will be recorded.

Responses

1 respondent

Doncaster Bassetlaw Hospitals NHS Trust NHS / Health Body

11 May 2015 PDF

Action Taken

The Trust completed an "observations project" including documentation of EWS on discharge and implemented a safety brief at shift changes. They are also planning to implement the i-Hospital whiteboard system and broaden advanced nurse practitioner roles. (AI summary)

View full response

Dear Dr Didcock Re Mr Philip Robinson D.O.B.
5.3.1972 D.O.D.
26.03.2014 am responding to the Regulation 28 Report dated 16 March 2015 sent to Mr Pinkerton, Chief Executive of Doncaster and Bassetlaw Hospitals NHS Foundation Trust: have been assisted in my response byb Acute Physician & Assistant Care Group Director Matron at Bassetlaw Hospital and Patient Safety Facilitator, Emergency Care Group. will respond to the issues raised as follows: The results from audits of compliance with safe discharge arrangements discharge stamp, including the recording of the EWS on discharge are unsatisfactory: The discharge stamp was trialled and found to be unsuccessful within ATC with its high turnover of patients Since this incident ATC has undergone an "observations project" which included the documentation and recognition of EWS on discharge: using

The i-Hospital white board system is due for implementation later this year. This will highlight which patients have a high EWS and the next due time of observations. On discharging patient from the system, the system will provide the nurse with an additional opportunity to assess EWS on discharge. The improved recording and communication of the EWS from Health Care assistant; to Nurse; to doctor as necessary, is not evident throughout the Hospital The safety brief at the end of the ward round involves the whole of the ward team including HCA'$ to improve communication of EWS between all the Multi-disciplinary team. The observations project has been completed and education undertaken with respect to the importance of clear communication between all members of the team. A safety brief is embedded in practice between shift change overs to improve whole team awareness of issues on the whole unit: Audits on ATC of documentation of EWS by HCA in the notes have consistently improved, reducing the chance of verbal communication failure. Recent audits show 100% compliance with the escalation policy on ATC. The medical staff involved in this Inquest do not agree with the SUI author, that an ECG was indicated during Mr Robinson's admission. There are no clear guidelines to assist medical staff with this clinical decision making when a patient presents with acute breathlessness An audit to monitor the threshold for performing a ECG has shown this is still not reliably performed when clinically indicated There are no clear national guidelines to assist medical staff when ordering ECGs in patients who present with breathlessness Acute medicine at Bassetlaw relies on early senior review by consultants. However variation in clinical judgement will occur. This incident has been communicated widely within the emergency care group by way of awareness: The risk of there being no one available to provide senior medical review when a registrar is absent remains an 'extreme risk' This is now no longer seen as an acceptable option to leave a SHO without registrar cover out of hours In 2015 to date there has been three occasions where no cover could be obtained_ On these occasions the consultant on-call was informed and provided extra support to the SHO. The issue around senior medical staffing remains a concern within the Trust We currently have an ongoing recruitment programme and are considering alternative ways to utilise senior staff within the trust to support this. The hospital 24/7 program is aimed at providing senior nurse practitioner cover to support the hospital out of Similar hospital sites have implemented this system with outcomes with regards patient safety: The i-Hospital is not yet in place: Implementation is planned for June 2015,and there is potential for delay: Interim plans for a 'At a glance Board' are not clear, with confusion as to where the EWS will be recorded_ The "status at a glance" board is now embedded in practice on ATC The board shows the EWS Score and the next time observations are due to be performed. The i-Hospital program is progressing well and plans remain optimistic that it will be in place by late summer 2015 hours. good

trust that the above will allay your concerns_ Please do rot hesitate to revert back to me should you feel it necessary:

Report sections

Investigation and inquest

On the 4th April 2014, I commenced an investigation into the death of Philip Robinson, age 42 years. The investigation concluded at the end of the inquest on 28th January 2015. The conclusion of the inquest was a Narrative: Philip Robinson died on the 26th March 2014 at Bassetlaw Hospital from an acute Myocardial Infarction. He had severe coronary artery disease. He had been discharged the previous day, with the significance of his clinical condition not appreciated by the treating team.

Circumstances of the death

Mr Robinson was a reasonably fit man, although he did have risk factors for the development of early Coronary Artery disease. He developed symptoms of vomiting and breathlessness over the three days prior to his death, with coughing up blood and pain in his lower back and side. Two days prior to his death he was seen at the Emergency Department at Bassetlaw Hospital. He was sent home, but asked to return that afternoon as some investigations were abnormal. He was monitored overnight on the Assessment and Treatment unit, and had an episode of breathlessness during the night. On the morning of the 25th March, the day before his death, he was seen by a Consultant, and a scan organised, to look for a pulmonary embolus. Throughout the day Mr Robinsons National Early Warning Scores rose from 1 to 3. There was no escalation for medical review. He was discharged home again, and readmitted the following day in cardiac arrest from which he could not be resuscitated.

The Trust completed a Serious Untoward Incident report, produced an action plan, and submitted further statements and reports following the Inquest. All these documents went some way to addressing concerns raised in evidence, however, in my view there remain outstanding concerns that allow for the continuation of circumstances creating a risk that other deaths will occur if such matters are not addressed.

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Report details

Reference: 2015-0225
Date of report: 13 March 2015
Coroner: Elizabeth Didcock
Coroner area: Nottinghamshire

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: 8 May 2015 (estimated).

Sent to

Doncaster and Bassetlaw Hospitals NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.