Jason Bayley
PFD Report
All Responded
Ref: 2023-0392
All 1 response received
· Deadline: 13 Dec 2023
Coroner's Concerns (AI summary)
Repeated incorrect documentation of medication adherence in patient records, despite patient refusal, created a breakdown in communication and posed a risk of harm due to misunderstanding actual medication intake.
View full coroner's concerns
1. Mr Bayley became unwell on 25/12/22 and was admitted to hospital the following day with severe constipation, from which he died on 28/12/22.
2. On most days between 4/12/22 and 25/12/22 when he was a detained patient on Speedwell Ward at St. Andrew's Healthcare, Mr Bayley refused to take at least one of his daily doses of lactulose which he was prescribed as part of a regime of laxatives for constipation. While these refusals were documented in the Electronic Prescribing and Medicines Administration document, there were fourteen occasions when it was incorrectly documented that all medication had been taken under the 'Medication Adherence' section in the Rio notes.
3. The Rio notes are the daily working records to which all staff have access. The reporting of medication adherence is specifically prompted in the Rio notes. It is of concern that, owing to a breakdown in communication between staff, the Rio notes repeatedly stated that all medication had been taken when it had not.
4. I am concerned that accurate documentation of whether medication has been taken in the Rio notes is an important safeguard against harm and a mechanism to promote appropriate care planning. I am concerned that there may be a risk to the life of some patients if staff understand that medication has been taken when it has not.
2. On most days between 4/12/22 and 25/12/22 when he was a detained patient on Speedwell Ward at St. Andrew's Healthcare, Mr Bayley refused to take at least one of his daily doses of lactulose which he was prescribed as part of a regime of laxatives for constipation. While these refusals were documented in the Electronic Prescribing and Medicines Administration document, there were fourteen occasions when it was incorrectly documented that all medication had been taken under the 'Medication Adherence' section in the Rio notes.
3. The Rio notes are the daily working records to which all staff have access. The reporting of medication adherence is specifically prompted in the Rio notes. It is of concern that, owing to a breakdown in communication between staff, the Rio notes repeatedly stated that all medication had been taken when it had not.
4. I am concerned that accurate documentation of whether medication has been taken in the Rio notes is an important safeguard against harm and a mechanism to promote appropriate care planning. I am concerned that there may be a risk to the life of some patients if staff understand that medication has been taken when it has not.
Responses
Action Planned
St Andrews Healthcare acknowledges a discrepancy between the ePMA record and shift handover notes. They will take action to improve the accuracy of progress notes, but maintain that the primary system for medication management is the ePMA. (AI summary)
St Andrews Healthcare acknowledges a discrepancy between the ePMA record and shift handover notes. They will take action to improve the accuracy of progress notes, but maintain that the primary system for medication management is the ePMA. (AI summary)
View full response
Dear Madam,
Report issued under Regulation 28 of the Coroners (Investigations) Regulations 2013 to St Andrew’s Healthcare
1 Introduction
1.1 I write in response to the above matter and your report dated 17 October 2023. I have considered your report, spoken with colleagues and directed further action. For the purposes of this response I will refer to St Andrew's as "the Charity".
1.2 I would like to reassure you that the Charity takes the issue of the accuracy of its clinical records extremely seriously and ensures that it is setup to allow its clinical teams access to the information they need to care for the people in the Charity’s care. A summary of the structure of the Charity’s the Electronic Patient Record (EPR) is set out in this letter to provide you with some additional context.
1.3 I think it is also worth stressing that the evidence you heard at the inquest – from witnesses at the Charity and Queen Elizabeth Hospital – is that Mr Bayley received all of the dosages for the two other laxatives he was prescribed and the missed dosages of lactulose over a period of 4 weeks did not more than minimally or trivially contribute to his death. The witnesses you heard from the Queen Elizabeth Hospital outlined that Mr Bayley’s issue with constipation was a chronic problem that had probably developed over a number of years during which time Mr Bayley’s physical health had been monitored appropriately and included a high number of referrals to specialists at the Queen Elizabeth Hospital.
2 Explanation of the EPR
2.1 The Charity’s EPR consists of three core systems:
1. Rio: is an electronic patient records system that is designed to hold information about a person’s mental healthcare. It is not designed to hold information about the prescribing and administration of medicines without an additional module or system being used. Rio is also not designed to hold information about physical healthcare.
CEO
All St Andrew’s ward-based staff, including nursing colleagues, have access to the Rio system and receive training on how to use Rio during their induction. There is no need for ongoing training on Rio usage as colleagues develop competence by using it during every shift.
2. EMIS: is the system used to document physical healthcare. This system is used to document physical healthcare investigations, contacts and results. Key information from this system is then automatically transferred into Rio. The EMIS record is akin to a primary healthcare record created by a GP surgery, so the structure of the health record is no different to a person living in the community or a psychiatric hospital that does not have the benefit of an internal physical healthcare resource and has its patients registered at a local GP surgery.
This system is mainly used by member of the physical healthcare team and doctors.
3. ePMA: is the system used for the administration and prescription of medication. This is the system that prescribers and administrators of medication will use to setup and administer a prescription of medication. It is the primary record that the key personnel, such as doctors, registered nurses and pharmacists will consult and review when considering issues that relate to a patient’s medication.
2.2 Rio is the primary system used on a day to day basis by the team on the ward. Due to this reason a patient’s Rio record has a number of links in it that enable the Rio user to view information from both EMIS and ePMA. The reasons for this are twofold insofar as some members of the team will not have access to EMIS and/or ePMA and also that it means that all of the information is available in one place, which is beneficial when reviewing a patient.
2.3 Given the ePMA records are transferred into Rio the correct information is available on medication concordance, but there is a risk that some of the information in the Rio progress notes could be inaccurate due to human error.
2.4 We have enclosed with this response a series of the screenshots of the Rio system to provide a visual explanation of how medication information stored in ePMA is available in Rio.
3 Investigations Undertaken
3.1 Having compared the missed doses of lactulose with the inaccurate Rio notes we have noted that on every occasion the Rio note was made by a colleague who was different to the one who administered the medication. During this period, where Mr Bayley missed a dose of lactulose and the Rio note documenting the shift handover was made by the person who administered his medication the Rio note is accurate. The staff making these notes vary in seniority from healthcare assistants to a deputy ward manager.
3.2 It would appear that the reason for the discrepancy between the ePMA record and the shift handover Rio note is the author not being aware of what medication a patient did and did not accept. The Charity is going to speak with all the colleagues who did not make accurate entries to establish the reason for this and to remind them of the importance of accurate record keeping in management supervisions.
4 Actions Taken
4.1 In order to address the issue with the inaccuracy of the Rio notes that relate to medication the Charity is undertaking the following actions:
Action 1: Reminding staff of the importance of good record keeping
4.2 The Charity has commissioned its Clinical Audit Team to undertake an audit reconciling Rio notes that relate to medication with the ePMA records. This will enable the Charity to review the extent of the issue that is the subject of the Regulation 28 report.
Action 2: Reminding staff of the importance of good record keeping
4.3 The Charity has a weekly clinical briefing called the Pulse which is received by all colleagues. We have included a message on the importance of accurate record keeping as well as another on the importance of documenting in Rio if a patient misses a dose of medication.
Action 3: Ensuring CPUMs review EPMA data
4.4 The Charity senior clinicians have communicated to their medical colleagues that every Care Plan Update Meeting/Ward Round should include a review of the last two weeks medication records on ePMA. This will ensure missed doses of medication will be noticed even if the Rio notes are incorrect.
Action 4: Investigating a technical solution
4.5 The Charity is currently undertaking a project to consider if ePMA can automatically make a Rio progress note documenting medication administration events. This would negate the need for this information to be included in the shift summary notes.
4.6 In addition, the Charity is investigating if an ePMA can send a patient’s responsible clinician an alert if consecutive doses of medication are missed by a patient. In addition to the technical feasibility of this proposed development, the Charity also needs to consider the effect of ‘alert fatigue’ in the sense that the effectiveness of such alerts will be reduced if key clinicians receive too many alerts as they will start to be ignored.
5 Summary
5.1 Having considered your report, we acknowledge that there should not have been a discrepancy between Mr Bayley’s ePMA record and the shift handover notes documented in his Rio progress notes.
5.2 The Charity will take the actions outlined above in order to improve the accuracy of the progress notes.
5.3 We would also highlight that you may not have been provided with detailed information of how the Charity’s EPR systems operate and are reviewed, which would have given you a better understanding of how the ePMA is used by clinicians. The Charity’s position is that the prominent system for checking the prescribing and administration of medication is ePMA which is regularly checked by doctors and is used by nurses at every instance of medication administration. There are therefore controls in place which address the risk of incorrect information about medication administration being entered into the progress notes of Rio, which is not the main system for medication management.
5.4 Senior clinicians in the Charity have considered your concern that “accurate documentation of whether medication has been taken in the Rio notes is an important safeguard against harm and a mechanism to promote appropriate care planning.” The view of the Charity’s senior clinical leadership team is that there is no reason for the discrepancy between the ePMA record and the Rio progress notes, but that the Rio progress notes documenting medication concordance are a secondary safeguard as the primary safeguards are the ePMA records, regular reviews of a patient’s care and the Patient Safety Dashboard. It may be that these factors were not clearly explained at the inquest touching upon Mr Bayley’s death.
5.5 I hope this response goes some way to address the concerns you have highlighted in your report.
Report issued under Regulation 28 of the Coroners (Investigations) Regulations 2013 to St Andrew’s Healthcare
1 Introduction
1.1 I write in response to the above matter and your report dated 17 October 2023. I have considered your report, spoken with colleagues and directed further action. For the purposes of this response I will refer to St Andrew's as "the Charity".
1.2 I would like to reassure you that the Charity takes the issue of the accuracy of its clinical records extremely seriously and ensures that it is setup to allow its clinical teams access to the information they need to care for the people in the Charity’s care. A summary of the structure of the Charity’s the Electronic Patient Record (EPR) is set out in this letter to provide you with some additional context.
1.3 I think it is also worth stressing that the evidence you heard at the inquest – from witnesses at the Charity and Queen Elizabeth Hospital – is that Mr Bayley received all of the dosages for the two other laxatives he was prescribed and the missed dosages of lactulose over a period of 4 weeks did not more than minimally or trivially contribute to his death. The witnesses you heard from the Queen Elizabeth Hospital outlined that Mr Bayley’s issue with constipation was a chronic problem that had probably developed over a number of years during which time Mr Bayley’s physical health had been monitored appropriately and included a high number of referrals to specialists at the Queen Elizabeth Hospital.
2 Explanation of the EPR
2.1 The Charity’s EPR consists of three core systems:
1. Rio: is an electronic patient records system that is designed to hold information about a person’s mental healthcare. It is not designed to hold information about the prescribing and administration of medicines without an additional module or system being used. Rio is also not designed to hold information about physical healthcare.
CEO
All St Andrew’s ward-based staff, including nursing colleagues, have access to the Rio system and receive training on how to use Rio during their induction. There is no need for ongoing training on Rio usage as colleagues develop competence by using it during every shift.
2. EMIS: is the system used to document physical healthcare. This system is used to document physical healthcare investigations, contacts and results. Key information from this system is then automatically transferred into Rio. The EMIS record is akin to a primary healthcare record created by a GP surgery, so the structure of the health record is no different to a person living in the community or a psychiatric hospital that does not have the benefit of an internal physical healthcare resource and has its patients registered at a local GP surgery.
This system is mainly used by member of the physical healthcare team and doctors.
3. ePMA: is the system used for the administration and prescription of medication. This is the system that prescribers and administrators of medication will use to setup and administer a prescription of medication. It is the primary record that the key personnel, such as doctors, registered nurses and pharmacists will consult and review when considering issues that relate to a patient’s medication.
2.2 Rio is the primary system used on a day to day basis by the team on the ward. Due to this reason a patient’s Rio record has a number of links in it that enable the Rio user to view information from both EMIS and ePMA. The reasons for this are twofold insofar as some members of the team will not have access to EMIS and/or ePMA and also that it means that all of the information is available in one place, which is beneficial when reviewing a patient.
2.3 Given the ePMA records are transferred into Rio the correct information is available on medication concordance, but there is a risk that some of the information in the Rio progress notes could be inaccurate due to human error.
2.4 We have enclosed with this response a series of the screenshots of the Rio system to provide a visual explanation of how medication information stored in ePMA is available in Rio.
3 Investigations Undertaken
3.1 Having compared the missed doses of lactulose with the inaccurate Rio notes we have noted that on every occasion the Rio note was made by a colleague who was different to the one who administered the medication. During this period, where Mr Bayley missed a dose of lactulose and the Rio note documenting the shift handover was made by the person who administered his medication the Rio note is accurate. The staff making these notes vary in seniority from healthcare assistants to a deputy ward manager.
3.2 It would appear that the reason for the discrepancy between the ePMA record and the shift handover Rio note is the author not being aware of what medication a patient did and did not accept. The Charity is going to speak with all the colleagues who did not make accurate entries to establish the reason for this and to remind them of the importance of accurate record keeping in management supervisions.
4 Actions Taken
4.1 In order to address the issue with the inaccuracy of the Rio notes that relate to medication the Charity is undertaking the following actions:
Action 1: Reminding staff of the importance of good record keeping
4.2 The Charity has commissioned its Clinical Audit Team to undertake an audit reconciling Rio notes that relate to medication with the ePMA records. This will enable the Charity to review the extent of the issue that is the subject of the Regulation 28 report.
Action 2: Reminding staff of the importance of good record keeping
4.3 The Charity has a weekly clinical briefing called the Pulse which is received by all colleagues. We have included a message on the importance of accurate record keeping as well as another on the importance of documenting in Rio if a patient misses a dose of medication.
Action 3: Ensuring CPUMs review EPMA data
4.4 The Charity senior clinicians have communicated to their medical colleagues that every Care Plan Update Meeting/Ward Round should include a review of the last two weeks medication records on ePMA. This will ensure missed doses of medication will be noticed even if the Rio notes are incorrect.
Action 4: Investigating a technical solution
4.5 The Charity is currently undertaking a project to consider if ePMA can automatically make a Rio progress note documenting medication administration events. This would negate the need for this information to be included in the shift summary notes.
4.6 In addition, the Charity is investigating if an ePMA can send a patient’s responsible clinician an alert if consecutive doses of medication are missed by a patient. In addition to the technical feasibility of this proposed development, the Charity also needs to consider the effect of ‘alert fatigue’ in the sense that the effectiveness of such alerts will be reduced if key clinicians receive too many alerts as they will start to be ignored.
5 Summary
5.1 Having considered your report, we acknowledge that there should not have been a discrepancy between Mr Bayley’s ePMA record and the shift handover notes documented in his Rio progress notes.
5.2 The Charity will take the actions outlined above in order to improve the accuracy of the progress notes.
5.3 We would also highlight that you may not have been provided with detailed information of how the Charity’s EPR systems operate and are reviewed, which would have given you a better understanding of how the ePMA is used by clinicians. The Charity’s position is that the prominent system for checking the prescribing and administration of medication is ePMA which is regularly checked by doctors and is used by nurses at every instance of medication administration. There are therefore controls in place which address the risk of incorrect information about medication administration being entered into the progress notes of Rio, which is not the main system for medication management.
5.4 Senior clinicians in the Charity have considered your concern that “accurate documentation of whether medication has been taken in the Rio notes is an important safeguard against harm and a mechanism to promote appropriate care planning.” The view of the Charity’s senior clinical leadership team is that there is no reason for the discrepancy between the ePMA record and the Rio progress notes, but that the Rio progress notes documenting medication concordance are a secondary safeguard as the primary safeguards are the ePMA records, regular reviews of a patient’s care and the Patient Safety Dashboard. It may be that these factors were not clearly explained at the inquest touching upon Mr Bayley’s death.
5.5 I hope this response goes some way to address the concerns you have highlighted in your report.
Sent To
- St Andrew’s Healthcare
Response Status
Linked responses
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56-Day Deadline
13 Dec 2023
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 24 January 2023 I commenced an investigation into the death of Jason Mark BAYLEY. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Natural Causes.
Circumstances of the Death
Jason suffered from paranoid schizophrenia and was detained under section 3 of the Mental Health Act 1983 for treatment at St. Andrew's Healthcare. He was prescribed clozapine on a long term basis, which carried a recognised risk of constipation which was treated with a regime of laxatives. Despite this, Jason had chronic constipation which was likely to have been developing over a period of many years. In December 2022 Jason's severe and chronic constipation led to intestinal pseudo-obstruction as a result of which he died at Queen Elizabeth Hospital in Birmingham on 28 December 2022. Following a post mortem/Based on information from the Deceased's treating clinicians the medical cause of death was determined to be: 1a Intestinal pseudo-obstruction (Megacolon) 1b Obstipation 1c II Lower respiratory tract infection
Copies Sent To
Department of Health and Social Care, CQC
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.