Bernard Cosgrove
PFD Report
All Responded
Ref: 2017-0285
All 1 response received
· Deadline: 22 Jan 2018
Response Status
Responses
1 of 1
56-Day Deadline
22 Jan 2018
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
On 25th September 2017 I concluded this inquest by way of a narrative conclusion. I indicated at the end of the inquest that it was my intention to write a report due to a concern about future deaths. Mr Cosgrove found himself being discharged back to the nursing home from where he had originally been admitted to hospital at a time when seemingly unknown to the hospital staff - including a senior member of the nursing staff for the ward - he had a dislocated hip. The fact that there was a problem with the hip seems to have become quickly apparent to care home staff upon his return to that home and to a General Practitioner who visited him although once the dislocation was in fact recognised it was treated conservatively given the patient's co-morbidities.
The concerns are: Despite an entry in the clinical records made by a doctor on 3rd March 2017 which refers to a rotating right leg, neither the issue he identifies nor his entry in the notes appear to have been appreciated by nursing staff who cared for Mr Cosgrove thereafter. A Sister who was a clear and helpful witness acknowledged in court that the issue identified by the doctor on 3rd March 2017 was not considered as part of his plan of care subsequently. This is despite the fact that between 3rd March 2017 and discharge from hospital he was seen regularly by staff with responsibility for physically rolling him with a view to providing pressure relief. Although from the evidence it is not known how the dislocation occurred the fact it does not appear to have been recognised over a period of 7 days is concerning and strongly suggests that staff paid insufficient regard to the patient’s previous medical record entries. Patients such as Mr Cosgrove should not find themselves being discharged from hospital in such circumstances and at a time when the medical professionals looking after his welfare are unaware of such an issue. But for the fact he was discharged from hospital on 10th March 2017 and that this resulted in the dislocation problem being identified, had he spent a lengthier period in hospital the dislocation and developing infection may well have continued to go unrecognised which raises a concern about how effectively patients are being monitored and their medical records are being considered by staff who are subsequently involved in that patient’s care. On this occasion once the dislocation issue was identified this did not substantially alter his care and he was treated conservatively, but in other circumstances not recognising the problem may have directly caused a death.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
The concerns are: Despite an entry in the clinical records made by a doctor on 3rd March 2017 which refers to a rotating right leg, neither the issue he identifies nor his entry in the notes appear to have been appreciated by nursing staff who cared for Mr Cosgrove thereafter. A Sister who was a clear and helpful witness acknowledged in court that the issue identified by the doctor on 3rd March 2017 was not considered as part of his plan of care subsequently. This is despite the fact that between 3rd March 2017 and discharge from hospital he was seen regularly by staff with responsibility for physically rolling him with a view to providing pressure relief. Although from the evidence it is not known how the dislocation occurred the fact it does not appear to have been recognised over a period of 7 days is concerning and strongly suggests that staff paid insufficient regard to the patient’s previous medical record entries. Patients such as Mr Cosgrove should not find themselves being discharged from hospital in such circumstances and at a time when the medical professionals looking after his welfare are unaware of such an issue. But for the fact he was discharged from hospital on 10th March 2017 and that this resulted in the dislocation problem being identified, had he spent a lengthier period in hospital the dislocation and developing infection may well have continued to go unrecognised which raises a concern about how effectively patients are being monitored and their medical records are being considered by staff who are subsequently involved in that patient’s care. On this occasion once the dislocation issue was identified this did not substantially alter his care and he was treated conservatively, but in other circumstances not recognising the problem may have directly caused a death.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
Responses
Response received
View full response
Dear Mr Wilson Re:Regulation 28 Report to Prevent Future_Deaths Bernard Cosgrove write in response to your Regulation 28 report to prevent future deaths relating to the care of Mr Bernard Cosgrove. Having reviewed your Regulation 28 initiated a review of the care which Mr Cosgrove received whilst an in-patient in the Trust: You have raised three concerns which shall address in turn: Despite an in clinical records made by a doctor on 3rd March 2017 which refers to a rotating right neither the issue he identifies nor his entry in the notes appear to have been appreciated by nursing staff who cared for Mr Cosgrove thereafter: A Sister who was a clear and helpful witness acknowledged in court that the issue identified by the doctor on 3rd March 2017 was considered as part of his plan of care subsequently. This is despite the fact that between 3rd March 2017 and discharge from hospital he was seen regularly by staff with responsibility for physically rolling him with view to providing pressure relief It is acknowledged that; sadly, the necessity to X-ray Mr Cosgrove's hip was not acted upon post the recommendation on the 3r March 2017_ The nursing staff continued with Mr Cosgrove's plan of care until his discharge on the 10th March 2017, this included a strict turning regime given his susceptibility to developing pressure damage, which for a patient like Mr Cosgrove could have been fatal. The Trust cannot; identify why, in Mr Cosgrove's case, there was no further record or action taken in terms of investigation into the potential findings from the 3rd March 2017 and for this we apologise However, having undertaken an internal review of Mr Cosgrove's care, lessons have been learnt and are being implemented. Although from the evidence it is not known how the dislocation occurred the fact it does not appear to have been recognised over period of 7 days is concerning and strongly suggests that staff paid insufficient regard to the patient's previous medical record entries. Patients such as Mr Cosgrove should not find themselves being discharged from hospital in such circumstances and at a time when the medical professionals looking after his welfare are unaware of such an issue: problem with his hip was suspected by the attending Physician who ordered an X-ray on 3 March 2017 . Unfortunately this Physician was locum who left on that date and the outstanding request for an X-ray investigation was not pursued by his successor who was also a locum. Since that time the Trust has introduced an electronic tracking system on every ward RESEARCH MATTERS AND SAVES LivES TODAY'S RESEARCH 5 TOMORROW'S CARE Blackpool Teaching Hospitals Is Centre of Clinical and Resoarch Excellence providing quality Up to date care We are actively involved in undertaking research to improve treatment of our pationts_ member of tha healthcare team may discuss curent clinical trials with you: INVESTORS disability Hoallh core Chairman: Mr lan Johnson MA; LLM Gold confident rdorcaatioust IN PEOPLE Chief Executlve: Wendy Swift COMMITTED the entry leg, not
where critical activities are flagged until have been actioned: hip X-ray would now be identified as a critical activity can assure you that such an oversight could not now occur But for the fact he was discharged from hospital on IOth March 2017 and that this resulted in the dislocation problem identified, had he spent a lengthier period in hospital the dislocation and developing infection may well have continued to go unrecognised which raises a concern about how effectively patients are being monitored and their medical records are being considered by staff who are subsequently involved in that patient'$ care: On this occasion once the dislocation issue was identified this did not substantially alter his care and he was treated conservatively; but in other circumstances not recognising problem may have directly caused a death: The Trust notes your concern in terms of other potential circumstances where not recognising issues or recording specific history within patient notes could lead to future problems and we are working hard to eradicate such problems We work closely with our staff in terms of practice development and continued professional development through Ward based education, updates and reminders of their professional responsibility in terms of patient care and contemporaneous recording of observations and notes_ hope the Trust's response assists you in addressing your concerns.
where critical activities are flagged until have been actioned: hip X-ray would now be identified as a critical activity can assure you that such an oversight could not now occur But for the fact he was discharged from hospital on IOth March 2017 and that this resulted in the dislocation problem identified, had he spent a lengthier period in hospital the dislocation and developing infection may well have continued to go unrecognised which raises a concern about how effectively patients are being monitored and their medical records are being considered by staff who are subsequently involved in that patient'$ care: On this occasion once the dislocation issue was identified this did not substantially alter his care and he was treated conservatively; but in other circumstances not recognising problem may have directly caused a death: The Trust notes your concern in terms of other potential circumstances where not recognising issues or recording specific history within patient notes could lead to future problems and we are working hard to eradicate such problems We work closely with our staff in terms of practice development and continued professional development through Ward based education, updates and reminders of their professional responsibility in terms of patient care and contemporaneous recording of observations and notes_ hope the Trust's response assists you in addressing your concerns.
Report Sections
Investigation and Inquest
The medical cause of death was recorded as follows:
1 a Bronchopneumonia 1 b Chronic obstructive pulmonary disease
11 Severe coronary artery atheroma, Left ventricular hypertrophy, Pyelonephritis, Hip joint infection associated with dislocated hip prosthesis
Narrative conclusion:
In December 2016 Bernard Cosgrove lost his balance as he made his way to his front door at his home and suffered a fracture of his right neck of femur which was surgically repaired. On 28th February 2017 he was admitted to hospital after he had been observed to be unresponsive. By the time he was discharged back to the care of the nursing home on 10th March 2017 it had not been fully recognised that his right hip joint had become dislocated during that period of hospitalisation and had started to become infected. He died at 0730 hours on 21st March 2017 at the nursing home where he resided from the effects of bronchopneumonia which had developed after his discharge from hospital. A subsequent post mortem examination confirmed his death was contributed to by significant heart disease and the hip joint infection.
1 a Bronchopneumonia 1 b Chronic obstructive pulmonary disease
11 Severe coronary artery atheroma, Left ventricular hypertrophy, Pyelonephritis, Hip joint infection associated with dislocated hip prosthesis
Narrative conclusion:
In December 2016 Bernard Cosgrove lost his balance as he made his way to his front door at his home and suffered a fracture of his right neck of femur which was surgically repaired. On 28th February 2017 he was admitted to hospital after he had been observed to be unresponsive. By the time he was discharged back to the care of the nursing home on 10th March 2017 it had not been fully recognised that his right hip joint had become dislocated during that period of hospitalisation and had started to become infected. He died at 0730 hours on 21st March 2017 at the nursing home where he resided from the effects of bronchopneumonia which had developed after his discharge from hospital. A subsequent post mortem examination confirmed his death was contributed to by significant heart disease and the hip joint infection.
Circumstances of the Death
Please see Narrative conclusion in section 3 above.
Copies Sent To
Manager of New Victoria Nursing Home
Care Quality Commission
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.