Source · Prevention of Future Deaths

Bertha Cray

Ref: 2014-0037 Date: 24 Jan 2014 Coroner: R Brittain Area: London Inner (North) Responses identified: 1 / 1 View PDF

Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.

Date 24 Jan 2014

56-day deadline 21 Mar 2014 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.

View full coroner's concerns

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. (1) On the account provided by the nursing staff, it is possible that inadvertent alteration of ‘nil by mouth’ signage could occur in the future, due to the apparent ease with which a doublesided sign can be turned and lack of action taken as a consequence of this clinical incident.

(2) On the account provided by the family, the ‘nil by mouth’ sign was replaced by some other means. The cause of this alteration is unclear, owing to the focus of the incident form being the ‘doublesided’ account, provided by the nursing staff. As such, it is possible that there could be a recurrence of this incident, as the cause has not been elucidated.

Responses

1 respondent

Barts Health NHS Trust NHS / Health Body

14 Mar 2014 PDF

Action Taken

The Trust has stopped using double-sided 'nil-by-mouth' signs with different instructions on each side, and will now issue signs with the same instruction on both sides. The family has been informed of the outcome of the investigation and seemed reassured by the changes made by the Trust. (AI summary)

View full response

Dear Sir

Inquest - Ms Bertha Cray

I write in response to your Regulation 28: Report to Prevent Future Deaths, dated 24 January 2014.

I am pleased to inform you that the investigation into your concerns regarding the ease of alteration of double- sided ‘nil-by-mouth’ signs at the bedside, as well the cause of the alteration, has now been concluded.

I am satisfied that this investigation has been sufficiently robust, in that we have scrutinised all relevant records, interviewed staff and have spoken with the family of Ms Cray to discuss their concerns and inform our investigation.

During the investigation, qualified nursing staff confirmed that the use of double-sided ‘nil-by-mouth’/’sips of water’ signs at the bedside was not the usual practice in the Trust. In this particular case, ‘sips of water’ had been written on the other side of the sign. This practice will now stop and new signs issued with the same instruction on both sides, so there is no option to amend the signs by writing on them.

As to the cause of alteration of the sign, the nurse involved was interviewed and explained that the ‘nil-by- mouth’ side of the sign was printed, whilst the writing on the other side was in green. This may explain why Ms Cray’s family gave evidence that there were two different signs.

We have taken this as an opportunity to review our processes to enhance future care. The family has been informed of the outcome of the investigation and seemed reassured by the changes made by the Trust.

Thank you for bringing your concerns to my attention. I hope you are assured I have taken them seriously and investigated them appropriately.

Report sections

Investigation and inquest

The investigation into the death of Bertha CRAY, aged 84, was commenced on 4 January 2013 and concluded at the end of the inquest on 22 January 2014. The conclusion of the inquest was narrative (Copy attached).

Circumstances of the death

Bertha CRAY underwent an uppergastrointestinal endoscopy on 11 December 2012 at Newham General Hospital. During this procedure her oesophagus was perforated. She was subsequently transferred to The Royal London Hospital where conservative (nonsurgical) management was initially undertaken. She was placed ‘nil by mouth’ in order to allow the perforation to heal. On 15th December the ‘nil by mouth’ sign was noted to have been changed to a sign which indicated that she could take ‘sips’ of water. A jug of water had therefore been provided by the kitchen staff. At the inquest there was conflicting evidence regarding how the sign came to be changed. Evidence from the nursing staff was that the sign was doublesided (comprising ‘nil by mouth’ on one side and ‘sips’ on the other) and had inadvertently been turned. The family were clear that the signs were singlesided, of different colours and could not have been inadvertently changed. There was also conflicting evidence as to whether Mrs Cray did ingest any water; the nursing staff provided evidence that she had not taken any sips, whilst the family were clear that she had. Evidence from the treating surgeon indicated that ingestion of a small volume of water is unlikely to have significantly contributed to Mrs Cray’s death. An incident form was completed but did not demonstrate that any action had been taken as a consequence of the investigation. Mrs Cray subsequently deteriorated and, despite surgical intervention, died on 29 December 2012 from bronchopneumonia, which resulted from the perforation and surgical treatment.

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Report details

Reference: 2014-0037
Date of report: 24 January 2014
Coroner: R Brittain
Coroner area: London Inner (North)

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: 21 Mar 2014 (estimated).

Sent to

Barts Health NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.