UK Inquiry Tracker

Catherine Burns

PFD Report All Responded Ref: 2018-0132

Date of Report 28 April 2018

Coroner Alan Wilson

Coroner Area Blackpool & Fylde

Response Deadline ✓ from report 24 June 2018

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 24 Jun 2018

Sent To

Blackpool Teaching Hospitals NHS Trust

Response Status

Responses 1 of 1

56-Day Deadline 24 Jun 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

I am concerned that staff were unable to provide the level of care to Catherine Burns that they would have liked to provide or which they felt was appropriate and that that this was due to the number of patients they were expected to care for. Consequently deterioration in her condition was not appreciated as quickly as it may otherwise have been. I am concerned that even during an extremely busy shift for a patient to be triaged as requiring assessment by a doctor and for that patient to then not be seen by a patient for over five hours risks future deaths and especially if the nursing staff are not able to monitor the patient as regularly as they may prefer. When giving consideration to writing a report to prevent future deaths Coroners are not limited to deaths which are felt to have been contributed to by the issue causing the Coroner some concern. As stated above the care afforded to Mrs Burns did not in my view alter the outcome for her but this should not prevent this report being written if I believe the duty upon me is met. I received impressive evidence from a Sister whose role was to co-ordinate the assessment area. She explained that during the entirety of the shift the staff had been dealing with approximately one third more patients than when they are performing at what is usually regarded as full capacity. However this was not an isolated incident and this had been the position throughout December, January, and February and that it has remained an issue which is persisting and cannot be solely attributed to what is sometimes described as “winter pressures”. It may well come as no surprise that the Emergency Department staff is facing these pressures and it may be that you feel that as a Trust you are doing all that you feel that you can to minimise the impact caused by the increased workload. Indeed I received helpful evidence during the inquest from the co-ordinator of the Emergency Department who explained that efforts have been made to review practices in order to make the system more efficient and hopefully be able to cope with over-capacity. Nevertheless, I believe that I have a duty to write this letter because I feel that there is a risk of future deaths caused or contributed to by staff not having the time to assess and care for patients due to their workloads meaning any potentially significant deterioration in a patient’s condition may go unrecognised or is under-appreciated and with serious consequences. 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

Blackpool Teaching Hospital NHS Trust

14 Jun 2018

Response received

View full response

Dear Mr Wilson Re:_Regulation 28 Report_to Prevent Future Deaths Mrs Catherine Burns write in response t0 your Regulation 28 report to prevent future deaths dated 28 April 2018 relating to the care of Mrs Catherine Burns_ Having reviewed your Regulation 28 initiated a review of the care which Mrs Burns received whilst an in-patient at the Trust. You raised the following concerns which shall address in turn. am concerned that staff were unable to provide the level of care to Catherine Burns that they would have liked to provide or which felt was appropriate and that that this was due to the number of patients they were expected to care for. Consequently deterioration in her condition was not appreciated as quickly as it may otherwise have been. In response to the increase demand o ED; the Emergency Department has undertaken a capacity and demand review of nursing and medical staffing and found that an increase in establishment is required. Accordingly, a paper has been prepared and submitted to the Executive Team for consideration . Until such time as an increase in establishment has been agreed, the Department continues to recruit substantively to vacancies and cover staffing on a to day, shift by shift basis_ There are robust governance structures in place to ensure that both medical and staffing gaps are identified early; escalated and managed safely. am concerned that even during an extremely busy shift for a patient to be triaged as requiring assessment by doctor and for that patient to then not be seen by a doctor for over five hours risks future deaths and especially if the nursing staff are not able to monitor the patient as regularly as they may prefer: The Better Care Now programme led by myself as Medical Director is in place to improve patient flow through the whole health system. As this programme begins to deliver, the pressure of overcrowding in the Emergency Department will begin to ease. As part of that programme of the work, the Department is developing an Escalation and Protocol to coordinate a consistent and effective response to an increase in demand. The criteria for escalation has been agreed and includes an escalation in the wait to be seen. Actions are being assigned to support the nurse and doctor in charge of the Emergency Department to manage the pressure effectively and gain the support required to de-escalate_ Escalation is being assessed through two hourly Safety Huddles and six times daily at bed meetings. RESEARCH MATTERS AND SAVES LIVES TODAY"S RESEARCH IS TOMORROWS CARE Blackpool Teaching Hospitals is Centre of Clinical and Research Excellence providing quality Up to date care We are actively involved in research improve treatment of our patients. member of the healthcare team may discuss current clinical trials with undertaking You: INVESTORS Idisability Health care Interim Chair: Mark Cullinan Gold confident Yoo caat GuSt IN PEOPLE Chief Executive; Wendy Swift COMMITTED Heys they safely day nursing Surge help

When giving consideration to writing a report to prevent future deaths Coroners are not limited to deaths which are felt to have been contributed to by the issue causing the Coroner As stated above the care afforded to Mrs Burns did not in my viewualteg the Olconee forne concern: should not prevent this report written if / believe the her but this duty upon me is met. 1 received impressive evidence from Sister whose role was to co-ordinate the assessment She explained that during the entirety of the shift the staff had been with area: thirdemore Patients than when they are performing atwhaf iSeesualyinegardedP3gOfuim ctelac one However this was not an isolated incident and this had been the position as capacity: Janbarerand February andshatec hacicemained tisis5ae behichthe persitsoinghaodghono December; attributed to what is sometimes described as "winter pressures cannot be solely Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above; the Better Care Now programme is designed to introduce service Primary, Community, and Secondary care to ensure patients receive treatment developments in possible and at the right time_ Working closely with the as close to home as NHS Improvement; the Division is embedding nitmber Ererpeover Care Improvement Programme and improvements which will have an impact on overcrowding in the Emergency Department: Useof the SAFER care bundle to improve patient management on wards and discharge Introduction of a centralised control room to improve the operational planning_ through the health system_ management of patient flow outsidesonghe Ebueatory Emergency Care Pathways to ensure that any patients that can be managed outside of the Emergency Department are managed in a different care model, Mental Health pathways identifying alternative routes of support for mental health patients in crisis Introducing therapies in to the Emergency Department to improve the speed of decisioe and SO accelerating decision for either admission Or discharge and, iherefore eeducing overrowdings Triage nurses on reception improved streaming to the Urgent Care Centre and fast initial assessment In your letter you went on to recognise the increased work load that the Trust in Emergency Department in specific is experiencing: You wi realise from tte natsonal greserahandhebe pressures are not peculiar to this health economy but affect major parts of the NHS INloneess Whachthese say that the Trust is in any way complacent about the matters that have raised of which is to you as concerns_ zhope that the extensive work described above gives some assurance that measures are mitigate the ongoing pressures as far as practicable. taken to

Report Sections

Investigation and Inquest

On 25th April 2018 I concluded an inquest into the death of Catherine Burns, born 03/05/41 and who was reported to have died at Blackpool Victoria Hospital on 05/12/17. The inquest concluded was: NATURAL CAUSES The medical cause of death was: 1 a LOBAR PNEUMONIA

Circumstances of the Death

Within box 3 of the Record of Inquest the circumstances surrounding this death were summarised as follows: Catherine Burns was admitted to hospital on 4th December 2017 complaining of abdominal pain and at 20.09 hours was triaged as requiring to be seen by a doctor within a period of ten minutes. She was first seen by a doctor no earlier than 1am on 5th December 2017 when it was felt that she was suffering from acute cholecystitis and prescribed intravenous antibiotics which were administered. Initially stable Catherine’s condition deteriorated at approximately 10.30 hours later that morning and by 12.50 hours she was observed to be having significant breathing difficulties. She went into respiratory arrest at 13.45 hours and her death was confirmed at 13.48 hours. A subsequent post mortem examination confirmed she had died from the effects of lobar pneumonia which had developed prior to hospital admission. In more detail: This death occurred on 5th December 2017. The Deceased was triaged as requiring an assessment by a doctor within ten minutes but was not seen by a doctor for at least approximately five hours. Although it could not be established that the outcome for her would have been different there is no doubt that the care afforded to her during the hospital admission was affected by the pressure which staff were expected to cope with. The primary reason why she was not seen by a doctor for such a period was due to the number of patients the staff in the Emergency Department had to deal with. I heard evidence from a Year 1 Speciality Trainee working in the Accident & Emergency department who was the doctor who first saw the patient and in his statement to this court he had commented that “During busy periods, such as this night, there are numerous patients triaged on red, orange, yellow and green throughout the department, it is agreed that patients are seen in time order unless there are specific concerns whereby a doctor, usually a Senior, will be asked to see a patient out of time order. No specific concerns were raised about Mrs Burns prior to her being seen by myself”. However I also received evidence from a Consultant Colorectal & General Surgeon who had been asked to provide an overview of the care afforded within the Emergency Department and he felt that despite the above he would ordinarily expect that even when it may not be possible for a doctor to assess a patient in accordance with the triage assessment [so within ten minutes for Mrs Burns] in which case the patient ought to be seen by a member of the nursing staff then the patient should be seen by a doctor within a 30 minute period and he acknowledged that the working conditions were behind the delay in this patient being assessed although he did not feel that any delay ultimately affected the outcome for Mrs Burns. After consultation with the surgical team a decision was taken that she be moved to the Assessment Unit but a bed was not available and she remained in the emergency department. During the morning of the 5th December from 10.30 through to 12.50 there was deterioration in her condition. By 12.50 hours Mrs Burns had deteriorated significantly. Her Daughter alerted the nursing staff. The Consultant on Call for the Emergency Department was alerted, realised the seriousness of her condition, but she arrested shortly afterwards. In my judgement the seriousness of her condition had not been fully appreciated at a time when the staff was so busy. As it transpired an independent pathologist reported that Mrs Burns died from lobar pneumonia which I found had developed prior to hospital admission. Indeed I found that Mrs Burns was likely to succumb to the effects of the pneumonia by the time she was triaged at the hospital.