Michael Jervis
PFD Report
All Responded
Ref: 2024-0712
All 1 response received
· Deadline: 24 Feb 2025
Coroner's Concerns (AI summary)
Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due to staff failure and the absence of a digital alert system.
View full coroner's concerns
(1) Repeated observations and NEWS scores were taken by numerous staff members which indicated that sepsis six should be triggered and that antibiotics were required but this did not happen.
(2) There was an absence of a digital alert on hospital software, which could have alerted staff to the need to implement sepsis six.
(2) There was an absence of a digital alert on hospital software, which could have alerted staff to the need to implement sepsis six.
Responses
Action Taken
The Trust has implemented a sepsis safety brief, made sepsis training mandatory, provided sepsis update training for doctors, and applied the sepsis screening tool to all blood pressure machines. They plan to implement a sepsis trigger within the new E-care system scheduled for roll-out in November 2025. (AI summary)
The Trust has implemented a sepsis safety brief, made sepsis training mandatory, provided sepsis update training for doctors, and applied the sepsis screening tool to all blood pressure machines. They plan to implement a sepsis trigger within the new E-care system scheduled for roll-out in November 2025. (AI summary)
View full response
Dear Mr Davies,
Re: The Late Michael Ramon Jervis – Regulation 28 PFD Report and Response
I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 30 December 2024 and received on the 31 December 2024. This was issued as a result of the inquest into the death of Mr Jervis which concluded on 24 October 2024. I would like to take this opportunity to express my sincerest condolences to the family of Mr Jervis for their loss. During the inquest, the evidence revealed matters giving rise to concern. These are as follows:
• Repeated observations and NEWS scores were taken by numerous staff members which indicated that sepsis six should have been triggered and that antibiotics were required, but this did not happen,
• There was an absence of a digital alert on hospital software, which could have alerted staff for the need to implement sepsis six. Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern.
Chief Medical officer’s office Royal Cornwall Hospital Truro Cornwall TR1 3LJ Tel: 01872 250000
Repeated observations and NEWS scores were taken by numerous staff members which indicated that sepsis six should have been triggered and that antibiotics were required but this did not happen: The Trust has undertaken the following action since the death of Mr Jervis; In the Acute Medical Unit (AMU) the matron has formulated an action plan to promote learning within the ward and wider care-group. This plan includes improving and monitoring compliance with mandatory sepsis training. The actions are:
a. To improve policy awareness and compliance by implementing a sepsis safety brief which will be shared Trust wide. This will be signed off and shared by April 2025. A copy can be provided if required.
b. The patient’s story will be shared with AMU staff (following consent), emphasising patient impact, to enhance staff awareness and understanding. The aim is to have this completed within the next six months and this will specifically focus upon neutropenic sepsis, hypothermia and the sepsis six bundle.
c. An educational awayday is being arranged for AMU staff, with a focus on sepsis and the deteriorating patient. This will be convened within the next six months.
d. To increase the compliance with sepsis training, improving to ‘amber’ (80%) compliance within four months and reaching a target of ‘green’ (90%) compliance within six months (excluding those on leave (i.e. maternity leave)
e. Sharing learning via Governance Leads in their areas at their local Governance meetings. Sepsis training for healthcare assistants and nurses became mandated in August 2024 and is now part of the Trust’s statutory and essential training. In addition, lunchtime training sessions have been arranged for our doctors with regards to sepsis and this has been implemented.
Image 2. Sepsis Screening Tool.
To continue to raise awareness and increase visibility, the Trust’s sepsis lead is applying the sepsis screening tool to all blood pressure machines. Sepsis awareness also forms part of the sepsis safety brief and communications have commenced from February 2025 with a sepsis digital sidebar and screen savers on all Trust computers.
There was an absence of a digital alert on hospital software, which could have alerted staff for the need to implement sepsis six: Unfortunately, Nervecentre (a national system) does not allow for this. However, RCHT is implementing a new e-Care digital electronic patient record (EPR) system and the sepsis lead nurse will be involved in the implementation to develop a sepsis alert/trigger to digitally ‘flag’ when the ‘sepsis six’ needs to be actioned. To summarise the above, the Trust are taking the following actions
1. Sepsis safety brief shared trustwide.
2. A patient story to be shared with AMU, which will have a focus on neutropenic sepsis, hypothermia and the sepsis bundle.
3. Sepsis training for nurses and health care assistants has become part of the mandatory and essential training from August 2024.
4. Sepsis update training has commenced with our doctors.
5. An educational awayday to be arranged for AMU staff, with a focus on sepsis and the deteriorating patient.
6. A training poster will be placed for reception staff in acute clinical areas (e.g. ED) to ensure that they are aware of the need to flag patients requiring neutropenic sepsis care.
7. RCHT plans to implement a sepsis trigger within the new E-care system – scheduled roll-out November 2025.
I hope that this letter provides both you and Mr Jervis’s family with assurance that the Trust has taken seriously the matter of concerns you raised in your report and that the Trust has taken appropriate action to prevent future deaths.
Re: The Late Michael Ramon Jervis – Regulation 28 PFD Report and Response
I write in response to the Regulation 28 Report to Prevent Future Deaths, dated 30 December 2024 and received on the 31 December 2024. This was issued as a result of the inquest into the death of Mr Jervis which concluded on 24 October 2024. I would like to take this opportunity to express my sincerest condolences to the family of Mr Jervis for their loss. During the inquest, the evidence revealed matters giving rise to concern. These are as follows:
• Repeated observations and NEWS scores were taken by numerous staff members which indicated that sepsis six should have been triggered and that antibiotics were required, but this did not happen,
• There was an absence of a digital alert on hospital software, which could have alerted staff for the need to implement sepsis six. Please find below the response from the Trust and the detail of the actions being taken in relation to the above concern.
Chief Medical officer’s office Royal Cornwall Hospital Truro Cornwall TR1 3LJ Tel: 01872 250000
Repeated observations and NEWS scores were taken by numerous staff members which indicated that sepsis six should have been triggered and that antibiotics were required but this did not happen: The Trust has undertaken the following action since the death of Mr Jervis; In the Acute Medical Unit (AMU) the matron has formulated an action plan to promote learning within the ward and wider care-group. This plan includes improving and monitoring compliance with mandatory sepsis training. The actions are:
a. To improve policy awareness and compliance by implementing a sepsis safety brief which will be shared Trust wide. This will be signed off and shared by April 2025. A copy can be provided if required.
b. The patient’s story will be shared with AMU staff (following consent), emphasising patient impact, to enhance staff awareness and understanding. The aim is to have this completed within the next six months and this will specifically focus upon neutropenic sepsis, hypothermia and the sepsis six bundle.
c. An educational awayday is being arranged for AMU staff, with a focus on sepsis and the deteriorating patient. This will be convened within the next six months.
d. To increase the compliance with sepsis training, improving to ‘amber’ (80%) compliance within four months and reaching a target of ‘green’ (90%) compliance within six months (excluding those on leave (i.e. maternity leave)
e. Sharing learning via Governance Leads in their areas at their local Governance meetings. Sepsis training for healthcare assistants and nurses became mandated in August 2024 and is now part of the Trust’s statutory and essential training. In addition, lunchtime training sessions have been arranged for our doctors with regards to sepsis and this has been implemented.
Image 2. Sepsis Screening Tool.
To continue to raise awareness and increase visibility, the Trust’s sepsis lead is applying the sepsis screening tool to all blood pressure machines. Sepsis awareness also forms part of the sepsis safety brief and communications have commenced from February 2025 with a sepsis digital sidebar and screen savers on all Trust computers.
There was an absence of a digital alert on hospital software, which could have alerted staff for the need to implement sepsis six: Unfortunately, Nervecentre (a national system) does not allow for this. However, RCHT is implementing a new e-Care digital electronic patient record (EPR) system and the sepsis lead nurse will be involved in the implementation to develop a sepsis alert/trigger to digitally ‘flag’ when the ‘sepsis six’ needs to be actioned. To summarise the above, the Trust are taking the following actions
1. Sepsis safety brief shared trustwide.
2. A patient story to be shared with AMU, which will have a focus on neutropenic sepsis, hypothermia and the sepsis bundle.
3. Sepsis training for nurses and health care assistants has become part of the mandatory and essential training from August 2024.
4. Sepsis update training has commenced with our doctors.
5. An educational awayday to be arranged for AMU staff, with a focus on sepsis and the deteriorating patient.
6. A training poster will be placed for reception staff in acute clinical areas (e.g. ED) to ensure that they are aware of the need to flag patients requiring neutropenic sepsis care.
7. RCHT plans to implement a sepsis trigger within the new E-care system – scheduled roll-out November 2025.
I hope that this letter provides both you and Mr Jervis’s family with assurance that the Trust has taken seriously the matter of concerns you raised in your report and that the Trust has taken appropriate action to prevent future deaths.
Sent To
- Royal Cornwall Hospital Trust
Response Status
Linked responses
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56-Day Deadline
24 Feb 2025
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
Report Sections
Investigation and Inquest
On 21 July 2024 I commenced an investigation into the death of 69-year-old Michael Ramon Jervis. The investigation concluded at the end of the inquest on 24 October 2024.
The medical cause of death was found to be
1a Neutropenic Sepsis 1b Chemotherapy II Germ Cell Testicular Cancer
The four questions - who, when, where and how – were answered as follows … Information Classification: PUBLIC Michael Ramon JERVIS died on 16 July 2023 at Royal Cornwall Hospital Truro from Neutropenic Sepsis, a recognized complication of chemotherapy treatment for Testicular Cancer. There was a 20-hour delay in the administration of antibiotics from the point at which clinical observations repeatedly indicated that antibiotics were clearly required. This delay in the administration of antibiotics more than minimally contributed to his death.
The conclusion as to the death is …
Michael Ramon JERVIS died from a recognized complication of necessary medical treatment contributed to by neglect.
The medical cause of death was found to be
1a Neutropenic Sepsis 1b Chemotherapy II Germ Cell Testicular Cancer
The four questions - who, when, where and how – were answered as follows … Information Classification: PUBLIC Michael Ramon JERVIS died on 16 July 2023 at Royal Cornwall Hospital Truro from Neutropenic Sepsis, a recognized complication of chemotherapy treatment for Testicular Cancer. There was a 20-hour delay in the administration of antibiotics from the point at which clinical observations repeatedly indicated that antibiotics were clearly required. This delay in the administration of antibiotics more than minimally contributed to his death.
The conclusion as to the death is …
Michael Ramon JERVIS died from a recognized complication of necessary medical treatment contributed to by neglect.
Circumstances of the Death
1. Mike was diagnosed with testicular cancer in May 2023 at Royal Cornwall Hospital Truro (RCHT). The cancer was treatable. The treatment plan was four cycles of chemotherapy. The aim of treatment was curative. Prior to the cancer diagnosis Mike was an independent, fit, and active man.
2. Mike underwent three cycles of chemotherapy. The cancer responded well to chemotherapy with the tumour markers falling from 18,000 to 18 by 5 July 2023.
3. Mike was discharged home on 9 July 2023 with a plan to admit him for the fourth round of chemotherapy.
4. However, Mike was re-admitted on 13 July 2023 to RCHT after becoming unwell. Bloods were taken on admission which revealed neutropenia. This is a condition which involves a significant weakening of the immune system and indicated a high risk of sepsis.
5. At 1600 hours 13 July 2023, an acute oncology nurse specialist recorded on Mike’s notes that antibiotics should be administered should Mike’s temperature fall below 36 or rise above 37.5. This note is consistent with hospital policy and guidance.
6. The court found that infections and sepsis are a recognized complication of chemotherapy because the treatment leaves patients immuno-compromised.
7. The court heard that a bundle of six measures are required when clinical indicators of sepsis are present, known as the ‘Sepsis Six’ bundle. The indicators for implementation of sepsis six, particularly for those immuno-compromised, include temperature above 37.5, below 36.
8. The six measures include administering fluids and administering antibiotics. The court found that of the six measures, antibiotics is the most important and should be administered within 60 minutes.
9. The court heard that the Sepsis Six bundle has been policy since 2006 at RCHT and nursing staff and doctors are expected to be aware of and implement sepsis six when indicated.
10. The first indication that sepsis six should be implemented was at 1710 hours on 13 July 2023 when observations gave a NEWS score of 4 in Information Classification: PUBLIC which low temperature (temp 35.6) and low blood pressure (78/42) should have resulted in a medical review and met the low threshold for IV antibiotics.
11. Thereafter numerous observations were taken over the following hours indicating that Mike met the low threshold for IV antibiotics.
12. In total, there was a 20-hour delay in the administration of antibiotics from 1710 hours on 13 July 2023 until 14:30 hours the following day.
13. The court found that this delay in the administration of antibiotics more than minimally contributed to his death and amounted to neglect.
2. Mike underwent three cycles of chemotherapy. The cancer responded well to chemotherapy with the tumour markers falling from 18,000 to 18 by 5 July 2023.
3. Mike was discharged home on 9 July 2023 with a plan to admit him for the fourth round of chemotherapy.
4. However, Mike was re-admitted on 13 July 2023 to RCHT after becoming unwell. Bloods were taken on admission which revealed neutropenia. This is a condition which involves a significant weakening of the immune system and indicated a high risk of sepsis.
5. At 1600 hours 13 July 2023, an acute oncology nurse specialist recorded on Mike’s notes that antibiotics should be administered should Mike’s temperature fall below 36 or rise above 37.5. This note is consistent with hospital policy and guidance.
6. The court found that infections and sepsis are a recognized complication of chemotherapy because the treatment leaves patients immuno-compromised.
7. The court heard that a bundle of six measures are required when clinical indicators of sepsis are present, known as the ‘Sepsis Six’ bundle. The indicators for implementation of sepsis six, particularly for those immuno-compromised, include temperature above 37.5, below 36.
8. The six measures include administering fluids and administering antibiotics. The court found that of the six measures, antibiotics is the most important and should be administered within 60 minutes.
9. The court heard that the Sepsis Six bundle has been policy since 2006 at RCHT and nursing staff and doctors are expected to be aware of and implement sepsis six when indicated.
10. The first indication that sepsis six should be implemented was at 1710 hours on 13 July 2023 when observations gave a NEWS score of 4 in Information Classification: PUBLIC which low temperature (temp 35.6) and low blood pressure (78/42) should have resulted in a medical review and met the low threshold for IV antibiotics.
11. Thereafter numerous observations were taken over the following hours indicating that Mike met the low threshold for IV antibiotics.
12. In total, there was a 20-hour delay in the administration of antibiotics from 1710 hours on 13 July 2023 until 14:30 hours the following day.
13. The court found that this delay in the administration of antibiotics more than minimally contributed to his death and amounted to neglect.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.