Surrey Sussex NHS Trust
NHS / Health Body
Action Taken
SASH has introduced mandatory training for newly qualified nurses on fluid balance and has issued a reminder to staff regarding the importance of accurately completing fluid balance charts. A Serious Incident Review Group has been formed to review SI investigations and reports. (AI summary)
View full response
Dear Dr Henderson, Re: Prevention of future death report; following an inquest into the death of Mrs Susan Geraty write in response to your prevention of future death report dated 27 January 2015 and received at our Trust on 3 February 2015. As this inquest was heard almost four and half months ago (on 19 September 2014), it has been a little more difficult to understand what is meant by some of the 'areas of concern'. apologise in advance if you feel missed your point on any particular issue_ Your report was addressed to three individuals at the Trust: myself;, the Medical Director and the Chief Nurse. The Act requires that "a person to whom a senior coroner makes report; must give the senior coroner a response to it"1_ hope that you will accept this letter as the Trust's joint response to your concerns. In future, would be grateful if any prevention of future death report could be addressed to me only, so that single co-ordinated response will result: Thank you for raising your concerns with me_ was of course aware of the death, our investigation report, your expert report and the conclusions of your inquest: Trust response to the matters of concern will now address each of the areas of concern that you raise: Coroners and Justice Act 2009, schedule 5 7(2). Putting people first An Associated University Hospital of Delivering excellent; accessible healthcare Brighton and Sussex Medical School have
1. Failure_to assess_monitor and record post-operative fluid balance: 2 Inadequate nursing records: 3 Inadequate fluid balance charts_ 5 Failure to recognise an acutely unwell patient Since this incident in 2012, SASH have implemented a number of improvements in the way that it records patient's fluid balance and in the way that it trains nursing staff with regards to recognising and acting on the identification of an acutely unwell patient and on monitoring post-operative fluid balance. The new Early Warning Score (EWS) paperwork which complies with the national standard (appendix 1) was launched in January 2014 and training on this has regular session on the Mandatory and Statutory Training (MAST): The Critical Care Outreach Team (CCOT) has made EWS training stressing the importance of ~detecting and managing the deteriorating patient: This is shown to all nursing staff attending MAST training and will be accessible through the Intranet later in the year. The Organisation-Wide Policy for Patient Observations (Vital Signs) in Adults is updated regularly to reflect the changes in the Trust regarding the paperwork and escalation process and this is available on the Trust's intranet An audit of the completion of the EWS chart has been completed but the results are being collated and will be finalised in April 2015. However; our EWS training has already been changed as a result of the findings to emphasise the importance of completing frequency of observations and monitoring plan sections correctly: Training is reviewed regularly based on feedback from staff. The EWS chart now has an SBAR (Situation , Background, Assessment, Recommendation) communication guide section, which outlines succinct way of relaying information between members of staff SBAR pads were introduced to the wards in January 2015 (appendix 2). Once completed, the note can be stuck into the patient's medical record, An audit will be conducted later in 2015 to review compliance_ The CCOT have also started to provide Sepsis/Acute Kidney Injury (AKI) and Fluid Balance Monitoring study for ward nurses. The morning session consists of teaching sepsis theory followed by relevant case studies. The afternoon session, concentrates on AKI theory and further case studies; the importance of fluid balance monitoring is also included in this session (appendix 3). Ward based teaching sessions have been held on Newdigate and Leigh wards in January 2015 by CCOT to educate the staff on patient assessment; AKI and fluid balance_ These sessions were well received and more sessions are planned for staff during the year: There is now a named CCOT nurse for the orthopaedic wards, who has worked with the staff on those wards to understand the staff's issues, and has then delivered AKI training to both trained and untrained ward nurses_ 2 day film, the day -
Following thepublication of 'Improving Outcomes for Patients with Proximal Femoral Fractures' byl and colleagues at the Queen's Medical Centre in Nottingham, a site visit is currently being arranged. The paper includes measures to significantly decrease incidences of AKI for this type of patient. Newdigate ward has been refurbished to include bays with increased monitoring and staffing: ALERTTM courses (a multi-professional course to train staff in recognising patient deterioration and act appropriately in treating the acutely unwell) started within the Trust last year, which includes section on AKI and fluid balance charts_ BEACH (Bedside emergency assessment course for health care staff) courses will start in April 2015, which will also stress the importance of fluid balance monitoring: There is Trust wide audit planned for 2015, to assess the completion of the fluid balance chart to monitor compliance_ Members of SASH staff have attended the Kent, Surrey and Sussex Academic Health Science Network Patient Safety Collaborative AKI on Wednesday 18th March 2015. In response to the Patient Safety Alert from NHS England in June 2014 'Standardising the early identification of Acute Kidney Injury, a medical lead for AKI was appointed for the Trust. From 2nd March 2015, patients identified with an acute reduction in renal function will be identified by the AKI algorithm in Apex; the Trust's pathology reporting tool. All level 2 and 3 results will be phoned through by the pathology team to the requesting doctor 24 hours a day: messages will show in Apex and Cerner alerting the user to any patient identified with AKI (appendix 4). Monthly mortality and morbidity meetings are held for all the specialties, to review the management of patients who have died and why_ This presents an opportunity to discuss the care received and ensure that lessons are learnt for the future. 4 Failure_to respond to legitimate concerns raised bY the family understand this to be a reference to the lack of action following the abnormal ECG result, This problem was identified in the Trust's investigation report and included as 'lesson learned' . Our report recommended that in future any investigation should be reviewed by the clinician ordering it;, or handed to another clinician if the results are not available immediately: The report also identified that this learning would be shared via the junior doctors induction programme and ward rounds, to highlight the new procedure_ SASH acknowledges that in this case, the nurse did not follow the normal and expected process of acting upon concerns raised by family. Learning from this incident has been central in the delivery of improvements and cascaded across our multi professional teams. This has been supported by the launch and roll out of our SBAR framework; and the use of patient stories for improvement: 3 again day New
There is now a whiteboard on every ward which details the names of the staff on duty and the name f the consultant in charge of the patient is now above every bed. The wards operate 'Meet the Matron' scheme, which is advertised on to the ward which gives patients and their families the times they are available to discuss any issues they may have. A notice by every bedside has the contact details for patients or their relatives to raise any concerns (appendix 5) Contact with patients and their family has been further strengthened by the new Duty of Candour policy. Open arrangements have now been designed into the Datix system to ensure the process has been followed when patients have been involved in an incident that has caused a level of harm to the patient (appendix 6).
6. Failure_of_the_SL report to_consider_or_acknowledge_dehydration as possible cause of acute renal failure As described above; the Sl report was produced many months before the expert suggested dehydration. The Sl report had been unable to identify the cause of the hyperkalaemia, in case which was complicated by a lack of any clinical signs and symptoms of dehydration either in life or at mortem, and in patient who had been conscious and documented to be eating and drinking well: The Trust does not agree that the investigation failed to recognise dehydration as the cause of AKI: The consultant who led the investigation felt that there were multiple causes in the deterioration in renal function which he considered at the time, including inadequate fluids, but accepts that this was not explicitly detailed in the report: In addition, the pathologist, having considered the medical records and the blood results , had stated in his post mortem report: "Potassium is present within muscle cells and if these are damaged by a rise in local pressure due to haemorrhage; there is a significant risk of muscular damage leading to raised potassium levels (hyperkalaemia): There is clear histological evidence of recent haemorrhage into the soft tissues of the right lower left; and this is associated with histological degenerative changes within the voluntary muscle It is therefore my opinion that the death was due to recognised complication of limb trauma and the cause of death is: Ia hyperkalaemic cardiac arrest Ib compartment syndrome Ic fracture of the right tibia and fibular (surgical repair). At the inquest, based on the expert report (which said that compartment syndrome was very unlikely, and that dehydration was likely), the pathologist amended his opinion to 1b to acute kidney injury instead. Our clinicians found the facts to be extremely unusual and not at all easy to explain: Had the pathologist identified an acute kidney injury as cause of death before the inquest; this may have assisted with this issue having been explored in more detail within the Sl report: entry Being post
All Sl reports are reviewed by the Clinical Commissioning Group (CCG) at their Serious Incident Scrutiny meeting: This took place on 18th July 2013 and their response was that felt the root cause was too long and asked for an assurance that the staff are fully aware of the fractured neck of femur pathway and routine monitoring of post-operative bloods. The Trust now has Serious Incident Review Group (appendix 7) made up of multi- disciplinary members which meets fortnightly to review Sl investigations and their reports. This presents an opportunity for the investigation team to give a thorough explanation of the investigations findings and a chance to review the report before closure_
1. Failure_to assess_monitor and record post-operative fluid balance: 2 Inadequate nursing records: 3 Inadequate fluid balance charts_ 5 Failure to recognise an acutely unwell patient Since this incident in 2012, SASH have implemented a number of improvements in the way that it records patient's fluid balance and in the way that it trains nursing staff with regards to recognising and acting on the identification of an acutely unwell patient and on monitoring post-operative fluid balance. The new Early Warning Score (EWS) paperwork which complies with the national standard (appendix 1) was launched in January 2014 and training on this has regular session on the Mandatory and Statutory Training (MAST): The Critical Care Outreach Team (CCOT) has made EWS training stressing the importance of ~detecting and managing the deteriorating patient: This is shown to all nursing staff attending MAST training and will be accessible through the Intranet later in the year. The Organisation-Wide Policy for Patient Observations (Vital Signs) in Adults is updated regularly to reflect the changes in the Trust regarding the paperwork and escalation process and this is available on the Trust's intranet An audit of the completion of the EWS chart has been completed but the results are being collated and will be finalised in April 2015. However; our EWS training has already been changed as a result of the findings to emphasise the importance of completing frequency of observations and monitoring plan sections correctly: Training is reviewed regularly based on feedback from staff. The EWS chart now has an SBAR (Situation , Background, Assessment, Recommendation) communication guide section, which outlines succinct way of relaying information between members of staff SBAR pads were introduced to the wards in January 2015 (appendix 2). Once completed, the note can be stuck into the patient's medical record, An audit will be conducted later in 2015 to review compliance_ The CCOT have also started to provide Sepsis/Acute Kidney Injury (AKI) and Fluid Balance Monitoring study for ward nurses. The morning session consists of teaching sepsis theory followed by relevant case studies. The afternoon session, concentrates on AKI theory and further case studies; the importance of fluid balance monitoring is also included in this session (appendix 3). Ward based teaching sessions have been held on Newdigate and Leigh wards in January 2015 by CCOT to educate the staff on patient assessment; AKI and fluid balance_ These sessions were well received and more sessions are planned for staff during the year: There is now a named CCOT nurse for the orthopaedic wards, who has worked with the staff on those wards to understand the staff's issues, and has then delivered AKI training to both trained and untrained ward nurses_ 2 day film, the day -
Following thepublication of 'Improving Outcomes for Patients with Proximal Femoral Fractures' byl and colleagues at the Queen's Medical Centre in Nottingham, a site visit is currently being arranged. The paper includes measures to significantly decrease incidences of AKI for this type of patient. Newdigate ward has been refurbished to include bays with increased monitoring and staffing: ALERTTM courses (a multi-professional course to train staff in recognising patient deterioration and act appropriately in treating the acutely unwell) started within the Trust last year, which includes section on AKI and fluid balance charts_ BEACH (Bedside emergency assessment course for health care staff) courses will start in April 2015, which will also stress the importance of fluid balance monitoring: There is Trust wide audit planned for 2015, to assess the completion of the fluid balance chart to monitor compliance_ Members of SASH staff have attended the Kent, Surrey and Sussex Academic Health Science Network Patient Safety Collaborative AKI on Wednesday 18th March 2015. In response to the Patient Safety Alert from NHS England in June 2014 'Standardising the early identification of Acute Kidney Injury, a medical lead for AKI was appointed for the Trust. From 2nd March 2015, patients identified with an acute reduction in renal function will be identified by the AKI algorithm in Apex; the Trust's pathology reporting tool. All level 2 and 3 results will be phoned through by the pathology team to the requesting doctor 24 hours a day: messages will show in Apex and Cerner alerting the user to any patient identified with AKI (appendix 4). Monthly mortality and morbidity meetings are held for all the specialties, to review the management of patients who have died and why_ This presents an opportunity to discuss the care received and ensure that lessons are learnt for the future. 4 Failure_to respond to legitimate concerns raised bY the family understand this to be a reference to the lack of action following the abnormal ECG result, This problem was identified in the Trust's investigation report and included as 'lesson learned' . Our report recommended that in future any investigation should be reviewed by the clinician ordering it;, or handed to another clinician if the results are not available immediately: The report also identified that this learning would be shared via the junior doctors induction programme and ward rounds, to highlight the new procedure_ SASH acknowledges that in this case, the nurse did not follow the normal and expected process of acting upon concerns raised by family. Learning from this incident has been central in the delivery of improvements and cascaded across our multi professional teams. This has been supported by the launch and roll out of our SBAR framework; and the use of patient stories for improvement: 3 again day New
There is now a whiteboard on every ward which details the names of the staff on duty and the name f the consultant in charge of the patient is now above every bed. The wards operate 'Meet the Matron' scheme, which is advertised on to the ward which gives patients and their families the times they are available to discuss any issues they may have. A notice by every bedside has the contact details for patients or their relatives to raise any concerns (appendix 5) Contact with patients and their family has been further strengthened by the new Duty of Candour policy. Open arrangements have now been designed into the Datix system to ensure the process has been followed when patients have been involved in an incident that has caused a level of harm to the patient (appendix 6).
6. Failure_of_the_SL report to_consider_or_acknowledge_dehydration as possible cause of acute renal failure As described above; the Sl report was produced many months before the expert suggested dehydration. The Sl report had been unable to identify the cause of the hyperkalaemia, in case which was complicated by a lack of any clinical signs and symptoms of dehydration either in life or at mortem, and in patient who had been conscious and documented to be eating and drinking well: The Trust does not agree that the investigation failed to recognise dehydration as the cause of AKI: The consultant who led the investigation felt that there were multiple causes in the deterioration in renal function which he considered at the time, including inadequate fluids, but accepts that this was not explicitly detailed in the report: In addition, the pathologist, having considered the medical records and the blood results , had stated in his post mortem report: "Potassium is present within muscle cells and if these are damaged by a rise in local pressure due to haemorrhage; there is a significant risk of muscular damage leading to raised potassium levels (hyperkalaemia): There is clear histological evidence of recent haemorrhage into the soft tissues of the right lower left; and this is associated with histological degenerative changes within the voluntary muscle It is therefore my opinion that the death was due to recognised complication of limb trauma and the cause of death is: Ia hyperkalaemic cardiac arrest Ib compartment syndrome Ic fracture of the right tibia and fibular (surgical repair). At the inquest, based on the expert report (which said that compartment syndrome was very unlikely, and that dehydration was likely), the pathologist amended his opinion to 1b to acute kidney injury instead. Our clinicians found the facts to be extremely unusual and not at all easy to explain: Had the pathologist identified an acute kidney injury as cause of death before the inquest; this may have assisted with this issue having been explored in more detail within the Sl report: entry Being post
All Sl reports are reviewed by the Clinical Commissioning Group (CCG) at their Serious Incident Scrutiny meeting: This took place on 18th July 2013 and their response was that felt the root cause was too long and asked for an assurance that the staff are fully aware of the fractured neck of femur pathway and routine monitoring of post-operative bloods. The Trust now has Serious Incident Review Group (appendix 7) made up of multi- disciplinary members which meets fortnightly to review Sl investigations and their reports. This presents an opportunity for the investigation team to give a thorough explanation of the investigations findings and a chance to review the report before closure_