Michael Burke
PFD Report
All Responded
Ref: 2024-0302
All 1 response received
· Deadline: 2 Aug 2024
Coroner's Concerns (AI summary)
Inadequate systems meant falls risk assessments were not completed or handed over during ward transfers, failing to manage patient fall risks effectively.
View full coroner's concerns
The Court heard evidence that risk assessments were to be carried out regularly on patients in relation to their falls risk. This is particularly important in circumstances where a patient was being transferred between wards/units within the hospital and where the risk to the patient may change due to the change in environment. Mr. BURKE was such a risk from falling whilst on the ward and therefore arrangements were required to be put in place to manage this risk, informed by a risk assessment. He had been admitted to Ipswich Hospital on 26th January 2023 following an unwitnessed fall at rehabilitation centre where he had been discharged to from Ipswich Hospital the previous day; 25th January 2023. Mr. BURKE was moved to a new ward on the 30th January 2023 following his admission, assessment and initial treatment. He was not risk assessed when transferred to the ward and the outstanding task to carry out the risk assessment had not been completed by the end of the shift during which he had been transferred onto the ward. This requirement was not handed over to the on-coming shift and a falls risk assessment had not been completed at the time Mr. BURKE sustained a fall on the ward. I am concerned that Ipswich Hospital has inadequate arrangements in place to both highlight circumstances where the requirement for risk assessments have not been completed and in the arrangements for the handover of tasks (particularly falls assessments) between shifts. I am further concerned that the failure to have adequate arrangements in place to address this raises a risk of future deaths which I am under a duty to bring to your attention.
Responses
Action Taken
ESNEFT sets a 6 hour assessment timeframe for falls risk assessments, from admission to hospital or change of ward. The Trust is working towards completing weekly checks on patient documentation and implements a Care Gap Analysis process for falls. (AI summary)
ESNEFT sets a 6 hour assessment timeframe for falls risk assessments, from admission to hospital or change of ward. The Trust is working towards completing weekly checks on patient documentation and implements a Care Gap Analysis process for falls. (AI summary)
View full response
Dear Mr Stewart
REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF MICHAEL JOHN BURKE WHICH CONLUDED ON 15 FEBRUARY 2024
I write in connection with the above mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 5 April 2024.
I would like to take this opportunity to extend my condolences to Mr Burke’s family for their loss.
The Regulation 28 Report to Prevent Deaths issued by yourself on 5 April 2024 highlighted concerns that Ipswich Hospital had inadequate arrangements in place to both highlight circumstances where the requirement for risk assessments have not been completed and the arrangements for the handover of tasks (particularly falls assessments) between shifts.
The information presented below is intended to describe the actions which have been taken/are being taken East Suffolk and North Essex NHS Foundation Trust to mitigate the risk of future deaths and address the concerns you have raised.
Completing falls risk assessments on admission/transfer to ward
East Suffolk and North Essex NHS Foundation Trust is committed to reducing the number of patient falls; minimising harm from falls that occur, whilst providing an enabling environment and effective rehabilitation.
Nationally there is no guidance on timeframes for carrying out falls assessments on admission/transfer to a ward but East Suffolk and North Essex NHS Foundation Trust recognise that a patient is most vulnerable to fall within the first 12 hours of presentation/admission.
For this reason East Suffolk and North Essex NHS Foundation Trust sets a 6 hour assessment timeframe, from admission to hospital or change of ward, for the assessment to be carried out, to make patients as safe as can be.
As part of the ongoing review process of our policies, the Trust has reviewed and updated their Falls Prevention Policy, which provides staff with guidance on the need to complete a moving and handling assessment and Falls Prevention Integrated Care Pathway within 6 hours of a decision to admit or transfer wards. This policy will be signed off at the Patient Safety Group on 18 June 2024.
Staff are trained on fall prevention as part of their induction training, Band 2 and upwards, as well as receiving continued training as highlighted below. The Falls Prevention policy is located on the Intranet and can be accessed by all staff.
The Trust has also carried out a review of the Integrated Patient Record, which forms an appendix to the Falls Prevention Policy, has been amended and now includes an updated Falls risk assessment proforma, which highlights the need for the assessment to be completed within the 6 hour time period of admission/change of ward.
The standard position is therefore that each patient admitted to the hospital or changing ward will have a moving and handling assessment and Falls Prevention Integrated Care Pathway completed within 6 hours of a decision to admit or transfer wards.
Handover of tasks during change of shift
On a daily basis there are 2 staff handovers, one when the daytime shift come on to the ward in the morning and one when the night time shift come on to the ward in the evening.
During the staff handover, the outgoing shift brief the incoming shift with information of the patients on the ward. This handover includes actions that need to be carried out. These actions are recorded on the staff handover sheet for the oncoming shift to action.
This would include circumstances were a moving and handling assessment and Falls Prevention Integrated Care Pathway still needed to be completed for a patient who has been admitted to or transferred to the ward. This action would be recorded on the handover sheet and then picked up by the oncoming shift members and completed.
The wards also use whiteboards to records actions that are required for patients and will ticked these off once they have been actioned.
Audit of paperwork
As part of the Trust’s accountability framework, patient notes are audited frequently to ensure that they are being completed correctly and to identify any issues with compliance in completing notes.
The Ward Manager carries out a weekly check of documentation and records on the online proforma the results of the check. This weekly check includes a review of the moving and handling assessment and Falls Prevention Integrated Care Pathway.
In addition the Matrons also carry out a monthly quality audit which is also completed using an online proforma. This monthly quality audit also includes a review of the falls documentation.
The Trust have implemented a Care Gap Analysis and After Action Review process for falls. The Care Gap Analysis will generate themes and trends with falls to help support change.
These audits and reviews enable the Trust to highlight any areas of learning and training that may arise. Compliance with completing the moving and handling assessment and the Falls Prevention Integrated Care Pathway for the final quarter of the 2023/2024 financial year was 94.08%.
Electronic Patient Records
The Trust has recently signed a contract to transition their patient records system to an electronic system, meaning that by 2025, all ESNEFT patient record keeping will be done electronically.
This will have the benefit of being more user friendly and provide greater compliance with completing documents, as the system is able to be programmed to ensure areas of information are documented before being able to proceed through the system.
It is also possible to set alerts that are triggered by timeframes to ensure staff are notified of any immediate actions that need to be carried out.
I hope the above information demonstrates the processes that are in place to ensure documentation is being completed in the appropriate manner and handed over to the oncoming shift. Through the various audits set out above the Trust review documentation and are able to highlight any areas of concern and address any areas of learning or training that need to be covered. If I can be of further assistance, please do not hesitate to contact me.
REGULATION 28 REPORT TO PREVENT DEATHS – INQUEST TOUCHING UPON THE DEATH OF MICHAEL JOHN BURKE WHICH CONLUDED ON 15 FEBRUARY 2024
I write in connection with the above mentioned Inquest and the Regulation 28 Report to Prevent Deaths issued by yourself on 5 April 2024.
I would like to take this opportunity to extend my condolences to Mr Burke’s family for their loss.
The Regulation 28 Report to Prevent Deaths issued by yourself on 5 April 2024 highlighted concerns that Ipswich Hospital had inadequate arrangements in place to both highlight circumstances where the requirement for risk assessments have not been completed and the arrangements for the handover of tasks (particularly falls assessments) between shifts.
The information presented below is intended to describe the actions which have been taken/are being taken East Suffolk and North Essex NHS Foundation Trust to mitigate the risk of future deaths and address the concerns you have raised.
Completing falls risk assessments on admission/transfer to ward
East Suffolk and North Essex NHS Foundation Trust is committed to reducing the number of patient falls; minimising harm from falls that occur, whilst providing an enabling environment and effective rehabilitation.
Nationally there is no guidance on timeframes for carrying out falls assessments on admission/transfer to a ward but East Suffolk and North Essex NHS Foundation Trust recognise that a patient is most vulnerable to fall within the first 12 hours of presentation/admission.
For this reason East Suffolk and North Essex NHS Foundation Trust sets a 6 hour assessment timeframe, from admission to hospital or change of ward, for the assessment to be carried out, to make patients as safe as can be.
As part of the ongoing review process of our policies, the Trust has reviewed and updated their Falls Prevention Policy, which provides staff with guidance on the need to complete a moving and handling assessment and Falls Prevention Integrated Care Pathway within 6 hours of a decision to admit or transfer wards. This policy will be signed off at the Patient Safety Group on 18 June 2024.
Staff are trained on fall prevention as part of their induction training, Band 2 and upwards, as well as receiving continued training as highlighted below. The Falls Prevention policy is located on the Intranet and can be accessed by all staff.
The Trust has also carried out a review of the Integrated Patient Record, which forms an appendix to the Falls Prevention Policy, has been amended and now includes an updated Falls risk assessment proforma, which highlights the need for the assessment to be completed within the 6 hour time period of admission/change of ward.
The standard position is therefore that each patient admitted to the hospital or changing ward will have a moving and handling assessment and Falls Prevention Integrated Care Pathway completed within 6 hours of a decision to admit or transfer wards.
Handover of tasks during change of shift
On a daily basis there are 2 staff handovers, one when the daytime shift come on to the ward in the morning and one when the night time shift come on to the ward in the evening.
During the staff handover, the outgoing shift brief the incoming shift with information of the patients on the ward. This handover includes actions that need to be carried out. These actions are recorded on the staff handover sheet for the oncoming shift to action.
This would include circumstances were a moving and handling assessment and Falls Prevention Integrated Care Pathway still needed to be completed for a patient who has been admitted to or transferred to the ward. This action would be recorded on the handover sheet and then picked up by the oncoming shift members and completed.
The wards also use whiteboards to records actions that are required for patients and will ticked these off once they have been actioned.
Audit of paperwork
As part of the Trust’s accountability framework, patient notes are audited frequently to ensure that they are being completed correctly and to identify any issues with compliance in completing notes.
The Ward Manager carries out a weekly check of documentation and records on the online proforma the results of the check. This weekly check includes a review of the moving and handling assessment and Falls Prevention Integrated Care Pathway.
In addition the Matrons also carry out a monthly quality audit which is also completed using an online proforma. This monthly quality audit also includes a review of the falls documentation.
The Trust have implemented a Care Gap Analysis and After Action Review process for falls. The Care Gap Analysis will generate themes and trends with falls to help support change.
These audits and reviews enable the Trust to highlight any areas of learning and training that may arise. Compliance with completing the moving and handling assessment and the Falls Prevention Integrated Care Pathway for the final quarter of the 2023/2024 financial year was 94.08%.
Electronic Patient Records
The Trust has recently signed a contract to transition their patient records system to an electronic system, meaning that by 2025, all ESNEFT patient record keeping will be done electronically.
This will have the benefit of being more user friendly and provide greater compliance with completing documents, as the system is able to be programmed to ensure areas of information are documented before being able to proceed through the system.
It is also possible to set alerts that are triggered by timeframes to ensure staff are notified of any immediate actions that need to be carried out.
I hope the above information demonstrates the processes that are in place to ensure documentation is being completed in the appropriate manner and handed over to the oncoming shift. Through the various audits set out above the Trust review documentation and are able to highlight any areas of concern and address any areas of learning or training that need to be covered. If I can be of further assistance, please do not hesitate to contact me.
Sent To
- East Suffolk and North Essex NHS Foundation Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
2 Aug 2024
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 15 February 2023 I commenced an investigation into the death of Michael John BURKE aged 75. The investigation concluded at the end of the inquest on 15 February 2024. The conclusion of the inquest was that: Narrative Conclusion - Michael John BURKE died due to advanced lung disease with a fractured neck of femur sustained due to a fall on 30th January 2023 having made a material contribution. The medical cause of death was confirmed as: 1a Hospital Acquired Pneumonia,, Acute Pulmonary Oedema 1b Acute Heart Failure, Cardiomegaly 1c Ischaemic Heart Disease, Chronic Obstructive Pulmonary Disease
Circumstances of the Death
Michael John BURKE was described by his family as a kind, loving, strong minded, dignified, intelligent man whose personality filled a room and who was a dedicated father and husband. Mr. Burke was diagnosed with asthma in 1969 for which he received treatment including steroid medication. This condition progressively worsened and he was diagnosed with Chronic Obstructive Pulmonary Disease (COPD) in 2008. Despite the significant impact this condition had on Mr. Burke’s wellbeing, particularly in his later years, he sought to maintain an active life to the fullest extent possible and was otherwise healthy. Mr. Burke’s COPD had worsened significantly towards the end of his life with an assessment in 2016 determining that he was suffering from advanced lung disease with only 16% use of his lungs. On the 30th December 2022 Mr. Burke was admitted to hospital with a suspected chest infection. Subsequent assessment determined that he was suffering from Community Acquired Pneumonia and an osteoporotic fracture of his vertebrae. He received treatment for his infection and conservative treatment for the fracture. His recovery was slow, however by 25th January 2023, Mr. Burke was medically fit for discharge; he had recovered from his pneumonia and was suitable to be stepped down for assessment as to care and rehabilitation needs in the community. He was discharged to a care home on 25th January 2023 for further assessment. The following evening, 26th January 2023, Mr. Burke was found collapsed on the lavatory floor by staff. Although not suffering a traumatic injury, Mr. Burke’s oxygen saturation levels were dangerously low and ambulance were called who transported Mr. Burke to hospital. On admission Mr. Burke was diagnosed with suffering from a chest infection and delirium caused by both his infection and the effect of the pain medication he was receiving. On 30th January 2023 Mr Burke suffered a fall on the ward whilst trying to get up out of his bed. Limited and inadequate measures had been put in place to mitigate his falls risk and no falls assessment had been undertaken. Mr. Burke was assessed and diagnosed as having suffered a fractured neck of femur. Surgery to address the fracture was delayed due to Mr. Burke’s general condition and very high risk of mortality from surgery. Mr. Burke’s condition continued to deteriorate and by the morning of 2nd February 2023 he was assessed as being at the end of life. Michael John BURKE died on the 2nd February 2023.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.