Source · Prevention of Future Deaths

Laura Hill

Ref: 2014-0064 Date: 17 Feb 2014 Coroner: Joanne Kearsley Area: Manchester (South) Responses identified: 1 / 1 View PDF

Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.

Date 17 Feb 2014

56-day deadline 14 Apr 2014 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.

View full coroner's concerns

Despite training being in existence in relation to the carrying out of Falls Risk Assessments there was a missed opportunity throughout the time Mrs Hill was in hospital for this to be carried out: There was no assessment on her admission to Ward C3 nor when she was transferred to Ward B6.

Responses

1 respondent

Stockport NHS Foundation Trust NHS / Health Body

31 Mar 2014 PDF

Action Taken

Stockport NHS Foundation Trust has instigated an escalation process for locating equipment, to be monitored via the Datix system. The nurses involved were formally counselled, and the case was presented to ward managers at a Surgical Sisters' meeting to disseminate lessons learned. (AI summary)

View full response

Dear Kearsley Re: Laura HILL 13.09.1936 (Deceased) Thank you for your letter of 17h February 2014, concerning the inquest %f the above named: As always, I am grateful to you for highlighting your concerns o the Regulation 28 'Report to prevent future deaths' and for providing me with an opportunity to respond: Ms Hill was admitted to Ward C3 o 28th September 2013 and on admission a falls risk assessment was completed. Ms Hill was identified to be at risk of falls and as result of that assessment bed rails were recommended The nurse who carried out the falls risk assessment has stated that; prior to attaching the falls risk wrist-band and completing the care plan, she went to find bed rails for the patient but could not find any immediately; she then became busy ad unfortunately forgot to go back to attach the falls risk wrist-band, fit bed rails and complete the care plan. On 1st October 2013, shortly after 01:00 hours, Ms Hill was transferred to Ward B6; however the falls risk assessment was not updated by the nursing staff, as per the trust policy, and on 2nc' October 2013 at 03.30 hours Ms Hill had an unwitnessed fall. Actions Ne have instigated an escalation process whereby, if any equipment cannot be located within the mmediate ward environment; staff must contact the senior nurses on 'professional cover' for the Business Sroups by bleep in the first instance to assist in locating the equipment: Should the bleep-holder be unable resolve the problem, this is to be escalated to the hospital site manager who will either locate the 'quipment or assist in the re-assessment of those currently in use across the hospital. This will be nonitored via the Datix incident reporting system to ascertain the need for further equipment to be vurchased, 5 a result of our investigations, in the case of the falls risk assessment undertaken on ward C3, the nurse ailed to follow Trust Policy in applying the falls risk wrist-band and in completing the falls risk' care plan; ad she done so this would have alerted other staff to the fact that the patient was at a higher risk of falls: he nurse concerned has been formally counselled on her failure to follow Trust the case of the nurse on ward who failed to update the falls risk assessment on transfer of Ms Hill; ne investigation found that she had also failed to follow Trust policy and she too has been formally Junselled regarding this_ 1is case has been presented by the managers of both wards involved to wider audience of ward anagers at a Surgical Sisters' meeting on March 2014, so that may disseminate the lessons arned to their respective teams_ our Health. Our Priority: Ms very Policy. B6, 17th they

I hope that this response answers your concerns and provides you with the assurance that the Trust is committed to improving the quality of care we give to all our patients. Please do not hegitate to contact me if you have any further questions regarding this matter.

Report sections

Investigation and inquest

On the 9th October 2013 commenced an investigation into the death of Laura Hill date of birth 13.09.1936_ The investigation was concluded at the end of the Inquest on the 5"h February 2014. The conclusion of the Inquest was that the deceased had died as a result of 1a) Pneumonia 2) Chronic Obstructive Pulmonary Disease, Ascending Cholangititis, dislocated left hip replacement requiring manipulation, Vascular Dementia_ Rheumatoid Arthritis and immunosuppression treatment: returned a conclusion that she had died as a result of natural causes_ CIRCUMSTANCES OF THE DEATH: On the 28ih September 2013 the deceased presented to Stepping Hill Hospital with acute abdominal pain and sepsis due to cholangitis_ She had an extensive complex medical history. She was admitted for treatment initially to the Surgical Assessment Unit. She was initially treated with antibiotics was not considered fit enough to undergo MRCP procedure. On the 1st October the deceased was transferred to ward B6, At 03.50am on the 2nd October the deceased was seen to fall from her bed, as a result she sustained a fracture to her left hip. This required manipulation and needed several attempts before this was successful, The deceased continued to deteriorate and died on the 8"h October 2013. The death was initially reported to the Coroner's Office with a cause of death offered as Ia) Pneumonia and 1b) Manipulation under anaesthesia for displacement of left total hip replacement: At the inquest heard evidence that the pneumonia was on balance due to her admitting condition and a number of cO-morbidities. However also heard evidence that on her admission to hospital no Falls Risk Assessment was carried out, that she was transferred between wards at 01.30am and that on arrival on Ward B6 where she had her fall there was again no Falls Risk Assessment carried out, It was noted that the deceased would in all likelihood have been assessed as requiring cot sides (albeit that does not prevent someone falling) and identified as at high risk of falls: and

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:

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Shared signals

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Report details

Reference: 2014-0064
Date of report: 17 February 2014
Coroner: Joanne Kearsley
Coroner area: Manchester (South)

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: 14 Apr 2014 (estimated).

Sent to

Stepping Hill Hospital

Part of a series

2 reports

2015-0092 All responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.