Jordan Howarth
PFD Report
All Responded
Ref: 2024-0236
All 2 responses received
· Deadline: 26 Jun 2024
Coroner's Concerns (AI summary)
Hospital care suffered from a lack of multidisciplinary collaboration, undocumented clinical decisions regarding antibiotics and ICU admission, and failure to follow established NEWS2 score protocols.
View full coroner's concerns
During 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. The inquest heard evidence that whilst there was input into Jordan’s care from both the microbiologist and the consultant physician there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics. The inquest was told that this decision was reached by the microbiology team and as a consequence, antibiotics were withheld without further alternative treatments being put in place despite how unwell he was and despite the fact that the treating clinicians were unclear about the cause of his deterioration.
2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point. All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
5. The inquest heard that despite the complexity of his case there was no evidence of a multi-disciplinary discussion/approach to assess his position fully and that it was unclear who was responsible for the continuity of his care.
2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point. All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
5. The inquest heard that despite the complexity of his case there was no evidence of a multi-disciplinary discussion/approach to assess his position fully and that it was unclear who was responsible for the continuity of his care.
Responses
Action Planned
The Department of Health and Social Care outlines the planned phased implementation of Martha's Rule, giving patients the right to request a rapid review of their case by someone outside their immediate care team, and describes NHS England's broader Managing Deterioration Safety Improvement Programme. (AI summary)
The Department of Health and Social Care outlines the planned phased implementation of Martha's Rule, giving patients the right to request a rapid review of their case by someone outside their immediate care team, and describes NHS England's broader Managing Deterioration Safety Improvement Programme. (AI summary)
View full response
Dear Ms Mutch, Thank you for the Regulation 28 report to prevent future deaths of 1 May 2024 about the death of Mr Jordan Howarth. I am replying as Minister with responsibility for patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Howarth’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises the following concerns:
1. Whilst there was input into Mr Howarth’s care from both the microbiologist and the consultant physician there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics.
2. The Critical Care Outreach Practitioner had identified that Mr Howarth needed to be moved to ICU urgently, which had to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Mr Howarth at that point and for declining to admit him at that point.
3. The Trust’s policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the Critical Care Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Mr Howarth that were not documented in his notes.
5. The inquest heard that despite the complexity of his case there was no evidence of a multidisciplinary discussion/approach to assess his position fully and that it was unclear who was responsible for the continuity of his care. A1
Most of these issues are operational in nature and I note that you have rightly sent your report to the hospital in question (Tameside General Hospital). It will be important that they consider these issues and findings fully and write to you with the actions and improvements they will be taking to address your findings and prevent a reoccurrence of what happened to Mr Howarth. In the meantime, it may be helpful if I outline the work we are doing at a national level to improve how the NHS detects and acts upon signs of deterioration. In February the Government and NHS England announced plans to implement Martha’s Rule in at least 100 acute or specialist NHS sites in England by March 2025. Martha’s Rule is an initiative that gives patients and their families who are concerned about deterioration in their physiological condition the right to initiate a rapid review of their case 24 hours a day from someone outside of their immediate care team. When requested, this rapid review will inform whether any new or additional action needs to be taken to help ensure patients receive the most appropriate care and treatment – which may include escalation. While some NHS Trusts already offer rapid review processes similar to Martha’s Rule called Call 4 Concern, others do not have an equivalent mechanism in place. In recognition of these variations in readiness, we are initiating a phased approach to implementing Martha’s Rule. NHS England are leading the process of identifying the 100+ sites that will participate in this first phase and supporting the development of their local processes. Alongside this, NHS England will develop proposals for national rollout in the next Spending Review period. Implementation of Martha’s Rule forms part of NHS England’s Managing Deterioration Safety Improvement Programme. This programme aims to reduce deterioration-associated harm by improving the prevention, identification, escalation and response to physical deterioration, through better system co-ordination and as part of safe and reliable pathways of care. In addition to phase one of Martha’s Rule implementation, the programme consists of the following workstreams:
• Continued testing and implementation of the standardised national deterioration tools addressing adults, children and young people, maternity and newborns across settings, incorporating patient, carer and family concerns; and
• Publication, implementation and spread of the PIER Framework (Prevent, Identify, Escalate and Respond to physical deterioration), to improve how the NHS supports staff across systems to manage deterioration and encourage greater involvement from patients, families, and carers. I hope this response is helpful. Thank you for bringing these concerns to my attention. Best Wishes, MARIA CAULFIELD A2
1. Whilst there was input into Mr Howarth’s care from both the microbiologist and the consultant physician there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics.
2. The Critical Care Outreach Practitioner had identified that Mr Howarth needed to be moved to ICU urgently, which had to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Mr Howarth at that point and for declining to admit him at that point.
3. The Trust’s policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the Critical Care Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Mr Howarth that were not documented in his notes.
5. The inquest heard that despite the complexity of his case there was no evidence of a multidisciplinary discussion/approach to assess his position fully and that it was unclear who was responsible for the continuity of his care. A1
Most of these issues are operational in nature and I note that you have rightly sent your report to the hospital in question (Tameside General Hospital). It will be important that they consider these issues and findings fully and write to you with the actions and improvements they will be taking to address your findings and prevent a reoccurrence of what happened to Mr Howarth. In the meantime, it may be helpful if I outline the work we are doing at a national level to improve how the NHS detects and acts upon signs of deterioration. In February the Government and NHS England announced plans to implement Martha’s Rule in at least 100 acute or specialist NHS sites in England by March 2025. Martha’s Rule is an initiative that gives patients and their families who are concerned about deterioration in their physiological condition the right to initiate a rapid review of their case 24 hours a day from someone outside of their immediate care team. When requested, this rapid review will inform whether any new or additional action needs to be taken to help ensure patients receive the most appropriate care and treatment – which may include escalation. While some NHS Trusts already offer rapid review processes similar to Martha’s Rule called Call 4 Concern, others do not have an equivalent mechanism in place. In recognition of these variations in readiness, we are initiating a phased approach to implementing Martha’s Rule. NHS England are leading the process of identifying the 100+ sites that will participate in this first phase and supporting the development of their local processes. Alongside this, NHS England will develop proposals for national rollout in the next Spending Review period. Implementation of Martha’s Rule forms part of NHS England’s Managing Deterioration Safety Improvement Programme. This programme aims to reduce deterioration-associated harm by improving the prevention, identification, escalation and response to physical deterioration, through better system co-ordination and as part of safe and reliable pathways of care. In addition to phase one of Martha’s Rule implementation, the programme consists of the following workstreams:
• Continued testing and implementation of the standardised national deterioration tools addressing adults, children and young people, maternity and newborns across settings, incorporating patient, carer and family concerns; and
• Publication, implementation and spread of the PIER Framework (Prevent, Identify, Escalate and Respond to physical deterioration), to improve how the NHS supports staff across systems to manage deterioration and encourage greater involvement from patients, families, and carers. I hope this response is helpful. Thank you for bringing these concerns to my attention. Best Wishes, MARIA CAULFIELD A2
Sent To
- Department of Health and Social Care
- Tameside General Hospital
Response Status
Linked responses
2 of 2
56-Day Deadline
26 Jun 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 17th April 2023, I commenced an investigation into the death of Jordan George James Fogg HOWARTH. The investigation concluded on the 20th March 2024 and the conclusion was one of Narrative: Died from the complications of a severe inflammatory response contributed to by neglect. The medical cause of death was 1a) Multi-Organ Failure on the background of a severe inflammatory response of unknown aetiology.
Circumstances of the Death
Jordan George James Fogg Howarth was a fit, healthy 25-year-old. He was admitted to Tameside General Hospital on 3rd April 2023 when he was unwell and deteriorating. The cause of his deteriorating condition was unclear. Tests found no surgical cause and no evidence of infection. It was suspected that there may be an auto immune reaction. There was no co-ordinated approach between specialists to identify the cause of his deterioration. There was no continuity of his care. On the evening of the 4th April he should have been escalated for a further critical care review under the Trust policy. It did not happen. He was moved to another ward. It was not recognised that he had triggered for a critical care review and that one had not been requested. On the morning of 5th April 2023, his condition was clearly deteriorating. A critical care outreach review at about 12:35 identified he needed to be admitted to ICU and a review be undertaken by an ICU consultant because all of his observations were consistent with his body shutting down and going into shock. His condition was escalated to the ICU consultant who decided not to review him and not to admit him to ICU despite his declining clinical picture. He should have been reviewed and admitted to ICU at that point. He was not admitted until five hours later when his condition had deteriorated even further. Earlier admission to ICU would have prevented such a rapid deterioration and allowed for earlier support to have been provided to his organs. Following admission to ICU his symptoms were consistent with his organs failing and requiring full support. He had a cardiac arrest at about 3:30am on 6th April 2023 and could not be resuscitated. On the balance of probabilities had he been reviewed and admitted to ICU following the first review by the critical care outreach team on 5th April he would not have died when he did. CORONER’S CONCERNS During 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. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. –
1. The inquest heard evidence that whilst there was input into Jordan’s care from both the microbiologist and the consultant physician there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics. The inquest was told that this decision was reached by the microbiology team and as a consequence, antibiotics were withheld without further alternative treatments being put in place despite how unwell he was and despite the fact that the treating clinicians were unclear about the cause of his deterioration.
2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point. All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
5. The inquest heard that despite the complexity of his case there was no evidence of a multi-disciplinary discussion/approach to assess his position fully and that it was unclear who was responsible for the continuity of his care.
1. The inquest heard evidence that whilst there was input into Jordan’s care from both the microbiologist and the consultant physician there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics. The inquest was told that this decision was reached by the microbiology team and as a consequence, antibiotics were withheld without further alternative treatments being put in place despite how unwell he was and despite the fact that the treating clinicians were unclear about the cause of his deterioration.
2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point. All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
5. The inquest heard that despite the complexity of his case there was no evidence of a multi-disciplinary discussion/approach to assess his position fully and that it was unclear who was responsible for the continuity of his care.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.