Alison Ross
PFD Report
All Responded
Ref: 2023-0343
All 1 response received
· Deadline: 16 Nov 2023
Coroner's Concerns (AI summary)
There is no clear guidance for monitoring patients who self-administer medications but do not take them at the time of dispensing, posing a risk to medication adherence.
View full coroner's concerns
It was brought to my attention that the competencies for those involved in medicine administration stated that medications should not be left at the bedside, but no guidance for the monitoring of medication for those patients who self administer prescriptions dispensed to them who do not take their medication at the time of dispensing it.
Responses
Action Taken
The trust has introduced a daily Safety Huddle on Balcombe Ward, is updating the Trust Medicines Management policy and competency assessment documentation, and is issuing a Medicines Governance Notice regarding bedside medication. Refresher education and training on medication administration has been completed and learning has been discussed with nursing staff. (AI summary)
The trust has introduced a daily Safety Huddle on Balcombe Ward, is updating the Trust Medicines Management policy and competency assessment documentation, and is issuing a Medicines Governance Notice regarding bedside medication. Refresher education and training on medication administration has been completed and learning has been discussed with nursing staff. (AI summary)
View full response
Dear Ms Andrews
Inquest into the death of Alison Mary Ross
Thank you for your letter of 21 September 2023, enclosing your formal report under Regulation 28 to Prevent Future Deaths.
First, I wish to convey my sincere condolences to Mrs Ross’ family. I am truly sorry that Mrs Ross died in our care.
Our new Divisional Director of Nursing for the Medicine Division has reviewed your concerns in relation to medication administration in conjunction with the safety, quality and governance team in her Division, and is confident that there is not an ongoing risk to patient safety in this respect. We have made significant improvements to the systems and processes in place following Mrs Ross’ sad death, and I will summarise these below.
We have introduced a Safety Huddle on Balcombe Ward at 10:30am everyday with the multidisciplinary team (MDT) to highlight any concerns in relation to staffing, patient concerns, or planned procedures.
The Trust Medicines Management policy is being updated to specifically include advice about medications at the patient bedside.
The Medicines Management competency assessment documentaiton is also being updated.
A Medicines Governance Notice is being issued to remind all clincial staff of the importance of not leaving medication at a patient’s bedside.
HM Area Coroner Ms Joanne Andrews Parkside Chart Way Horsham RH12 1XH
Letter by email only
15 November 2023
University Hospitals Sussex NHS Foundation Trust Trust Headquarters Royal Sussex County Hospital Eastern Road Brighton BN2 5BE
Work is underway to re-establish funding for a specific Medicine Division Ward Medicines Management Programme. The Principal Pharmacist for Medicines Safety, Quality and Governance is in discussions with the Chief Pharmacist to take this forward.
Refresher education and training regarding medication administration has been completed and this education programme is ongoing. This training is being delivered to the ward team by the Practice Development Nurses.
A reflective discussion with the nursing staff who cared for Mrs Ross has been undertaken to reinforce the learning.
Audits are undertaken to check that medication is not left at patient bedsides. A medicine management audit is on our safety software (Tendable) and this is being increased to a weekly item (from monthly). Furthermore, an extra question targetting this specific topic is being added to the audit to increase our assurance in this respect.
The learning from Mrs Ross’ case will be shared (anonymously) at the Medical Grand Round on 24 November 2023.
We have drafted a Patient Story which incorporates the learning and feedback from Mrs Ross’ family. This is to be shared at the Patient Safety Group meeting on 4 December 2023 and it will be cascaded to all Divisions to ensure there is widespread and far reaching safety learning.
The learning will also be shared at the Mortality and Morbidity meeting on 29 November 2023.
I am pleased that you were assured by the oral evidence from about the actions in the SI in relation to the Ascitic Drain Proforma. By way of an update, the Proforma incorporating revised anti-coagulant guidance, was reviewed by the Gastroenterology team on 3 November 2023, and is to be discussed at the Trust Thrombosis Committee. Following the feedback from these specialist groups, it will be submitted to the Medicines Governance Group for approval, and it’s use will be part of our audit programme in the New Year to ensure correct usage and efficacy. The Trust Anticoagulant Bridging Guidance is scheduled to be ratified at the Trust Thrombosis Committee. This is to be shared at the Patient Safety Group and it will be available to our staff on the intranet.
I hope this letter provides you and Mrs Ross’ family with assurance that we have taken the learning extremely seriously and have made significant improvements. Once again, my sincere condolences to Mrs Ross’ family.
Inquest into the death of Alison Mary Ross
Thank you for your letter of 21 September 2023, enclosing your formal report under Regulation 28 to Prevent Future Deaths.
First, I wish to convey my sincere condolences to Mrs Ross’ family. I am truly sorry that Mrs Ross died in our care.
Our new Divisional Director of Nursing for the Medicine Division has reviewed your concerns in relation to medication administration in conjunction with the safety, quality and governance team in her Division, and is confident that there is not an ongoing risk to patient safety in this respect. We have made significant improvements to the systems and processes in place following Mrs Ross’ sad death, and I will summarise these below.
We have introduced a Safety Huddle on Balcombe Ward at 10:30am everyday with the multidisciplinary team (MDT) to highlight any concerns in relation to staffing, patient concerns, or planned procedures.
The Trust Medicines Management policy is being updated to specifically include advice about medications at the patient bedside.
The Medicines Management competency assessment documentaiton is also being updated.
A Medicines Governance Notice is being issued to remind all clincial staff of the importance of not leaving medication at a patient’s bedside.
HM Area Coroner Ms Joanne Andrews Parkside Chart Way Horsham RH12 1XH
Letter by email only
15 November 2023
University Hospitals Sussex NHS Foundation Trust Trust Headquarters Royal Sussex County Hospital Eastern Road Brighton BN2 5BE
Work is underway to re-establish funding for a specific Medicine Division Ward Medicines Management Programme. The Principal Pharmacist for Medicines Safety, Quality and Governance is in discussions with the Chief Pharmacist to take this forward.
Refresher education and training regarding medication administration has been completed and this education programme is ongoing. This training is being delivered to the ward team by the Practice Development Nurses.
A reflective discussion with the nursing staff who cared for Mrs Ross has been undertaken to reinforce the learning.
Audits are undertaken to check that medication is not left at patient bedsides. A medicine management audit is on our safety software (Tendable) and this is being increased to a weekly item (from monthly). Furthermore, an extra question targetting this specific topic is being added to the audit to increase our assurance in this respect.
The learning from Mrs Ross’ case will be shared (anonymously) at the Medical Grand Round on 24 November 2023.
We have drafted a Patient Story which incorporates the learning and feedback from Mrs Ross’ family. This is to be shared at the Patient Safety Group meeting on 4 December 2023 and it will be cascaded to all Divisions to ensure there is widespread and far reaching safety learning.
The learning will also be shared at the Mortality and Morbidity meeting on 29 November 2023.
I am pleased that you were assured by the oral evidence from about the actions in the SI in relation to the Ascitic Drain Proforma. By way of an update, the Proforma incorporating revised anti-coagulant guidance, was reviewed by the Gastroenterology team on 3 November 2023, and is to be discussed at the Trust Thrombosis Committee. Following the feedback from these specialist groups, it will be submitted to the Medicines Governance Group for approval, and it’s use will be part of our audit programme in the New Year to ensure correct usage and efficacy. The Trust Anticoagulant Bridging Guidance is scheduled to be ratified at the Trust Thrombosis Committee. This is to be shared at the Patient Safety Group and it will be available to our staff on the intranet.
I hope this letter provides you and Mrs Ross’ family with assurance that we have taken the learning extremely seriously and have made significant improvements. Once again, my sincere condolences to Mrs Ross’ family.
Sent To
- University Hospitals Sussex NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
16 Nov 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 17 November 2022 I commenced an investigation into the death of Alison Mary ROSS aged 55. The investigation concluded at the end of the inquest on 20 September 2023. The conclusion of the inquest was that: Alison Mary Ross died on 11 November 2022 at the Princess Royal Hospital, Lewes Road, Haywards Heath, West Sussex from an intraabdominal haemorrhage caused by an ascitic drain procedure on 10 November 2022 to treat ascites resulting from decompensated chronic alcoholic liver disease.
Circumstances of the Death
Mrs Ross was admitted to hospital on 3 November 2022 and was found during admission to have abdominal ascites. On 9 November 2022 Mrs Ross was prescribed treatment doses of apixaban commencing on 10 November. This replaced the prophylactic dose of enoxaparin given previously. At the time of the prescription of apixaban she had been diagnosed with a DVT. She had an ascites drain inserted on 10 November 2022. At the time of the procedure Mrs Ross’ platelets were within normal range and she had an INR of 1.3 which was slightly above the normal range. Mrs Ross reported to the clinician during the morning ward round that she had not taken her oral medications that morning as she was too unwell. These were charted as including apixaban. There was also a Nurse present at that time. The clinician advised the Nurse and Mrs Ross that the anticoagulation would be stopped for 48 hours due to the procedure and charted this accordingly. The clinician inserted the drain at 13:30 without any reported complications. At 15:30 the clinician reviewed Mrs Ross with the drain still in situ. The Nurse who had been at the ward round was also present. At that time Mrs Ross reported relief from her symptoms and that she had since the start of the procedure taken her morning medications. There was no evidence that apixaban was omitted. There was no evidence as to what had happened to the medications that were not taken when dispensed. The clinician administered Tranexamic acid (TXA) and Vitamin K as preventative medications to mitigate the effects of the apixaban. At that time there were no clinical indications of bleeding. Around 30 minutes after the drain had been removed Mrs Ross started to demonstrate symptoms which may have been indicative of a bleed having occurred. Despite treatment to try and increase Mrs Ross’ clotting due to the location of the bleed she said died from the haemorrhage.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.