Norma Bruton
PFD Report
All Responded
Ref: 2023-0165
All 1 response received
· Deadline: 14 Jul 2023
Coroner's Concerns (AI summary)
The hospital's falls risk assessment form inadequately prompts staff to consider or document the presence and relevance of patient attachments, such as chest drains or IV infusions, in relation to falls risk.
View full coroner's concerns
1. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions.
2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls.
3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment.
2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls.
3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment.
Responses
Action Planned
The Trust will add a drop-down menu to the falls risk assessment to allow staff to record any equipment such as drains, and this will also be recorded in the Patient Handling Assessment Form. This change is expected to be implemented on 15th August 2023. (AI summary)
The Trust will add a drop-down menu to the falls risk assessment to allow staff to record any equipment such as drains, and this will also be recorded in the Patient Handling Assessment Form. This change is expected to be implemented on 15th August 2023. (AI summary)
View full response
Dear Ms McKinlay
Inquest touching the death of Norma Winifred Bruton Response to Regulation 28 Report to prevent future deaths
I write in response to the Regulation 28 Report made by you following the Inquest touching the death of Mrs Bruton which concluded on 18 May 2023.
University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered the concerns raised within your report to prevent future deaths, which relate to the falls risk assessment documents in particular prompts in relation to patients who may have chest drains or intravenous fusions in place.
Falls risk assessment I note that during the Inquest you heard evidence that the falls risk assessment did not include a prompt for staff to assess the impact of any equipment that they may require, such as in Mrs Bruton’s case, a chest drain, and whilst it was included within the manual handling assessment, the information was not automatically fed into the falls risk assessment.
To provide some background all patients admitted to UHB must be screened for their risk of falls. This includes a multifactorial risk assessment which identifies the patient’s individual risk factors for falling in hospital which can then be treated, managed or improved during their admission. These can include cognitive impairment, continence needs, falls history, unsuitable footwear, comorbidities or medication that may increase risk of falling, postural instability or mobility/balance problems and vision impairment. Combined with the falls risk assessment is a manual handling assessment that nursing staff are required to complete at the same time as the falls risk assessment. The manual handling form stipulates how a patient should mobilise in light of their falls risk factors. So the two, in practice, are considered alongside each other. The manual handling form is more detailed in regards to how patients can/should mobilise, and there is a question as to whether the patient, when walking, requires assistance with drips or attachments and this is to be taken into consideration when completing the assessment. In Mrs Bruton’s case she was assessed on 14 October 2022 as not being at risk of falls and her manual handling assessment noted her to be independent. The question around requiring assistance with drips or attachments when mobilising had not however been completed.
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The information recorded in the manual handling assessment has not been designed to automatically feed into the falls risk assessment as this was considered to be a duplication of information in the patient record. The recommendation is that these assessments are looked at in combination not isolation.
Our electronic records system (PICS) incorporates multiple assessments/records that when looked at in combination provides detailed guidance / overview of a patient’s status in regards to falls and mobility risk. Staff should therefore always refer to, and consider the following in combination; the falls risk assessment, the manual handling assessment (that provides a more detailed account of what mobility needs the patient has, such as attachments that may limit a person’s mobility, whether any specific mobility aids are required, and what level of supervision from staff is needed); also the Daily Care Plan, which details whether bed rails are required, any additional needs a person may have, and also demonstrates what their current needs are during that particular shift.
Updates to falls risk assessment document We have considered the concerns you have raised within your report to prevent future deaths and we are taking steps to add in a drop down menu, within the falls risk assessment, which will allow staff to select an appropriate option if a patient has any equipment, such as drains, in place. This will then also be recorded in the PHAF (Patient Handling Assessment Form) therefore attachments will be reflected in both risk assessments. This will further increase staff awareness of falls risk factors. There is a lead in time for the changes to be made to our PICS system, and we can confirm that this change is expected to take place on the 15th August 2023. In the meantime whilst waiting for the programming work to be completed, the Lead Nurse for Falls Prevention has attended and highlighted at Divisional Preventing Harm Groups, which are attended by ward managers, Matrons and Deputy Directors of Nursing, the importance of ensuring that attachments are recorded and considered as part of a person’s manual handling needs. This has also been discussed at the Operational Care Quality Group chaired by the Director of Nursing Quality, Safety and Innovation, and attended by all of the Divisional Deputy Directors of Nursing and Nursing Leads for patient harm groups. We have also updated our Trust Inpatient Falls Procedure so that this is further emphasised. Based on the review of our falls risk assessment and the updates we are making to PICS, we are confident that the systems and processes that we have in place are sufficient to minimise and manage the risk of falls of our patients.
I would like to assure you that the concerns raised within the Regulation 28 Report have been taken extremely seriously which I hope is demonstrated by our response above.
Inquest touching the death of Norma Winifred Bruton Response to Regulation 28 Report to prevent future deaths
I write in response to the Regulation 28 Report made by you following the Inquest touching the death of Mrs Bruton which concluded on 18 May 2023.
University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered the concerns raised within your report to prevent future deaths, which relate to the falls risk assessment documents in particular prompts in relation to patients who may have chest drains or intravenous fusions in place.
Falls risk assessment I note that during the Inquest you heard evidence that the falls risk assessment did not include a prompt for staff to assess the impact of any equipment that they may require, such as in Mrs Bruton’s case, a chest drain, and whilst it was included within the manual handling assessment, the information was not automatically fed into the falls risk assessment.
To provide some background all patients admitted to UHB must be screened for their risk of falls. This includes a multifactorial risk assessment which identifies the patient’s individual risk factors for falling in hospital which can then be treated, managed or improved during their admission. These can include cognitive impairment, continence needs, falls history, unsuitable footwear, comorbidities or medication that may increase risk of falling, postural instability or mobility/balance problems and vision impairment. Combined with the falls risk assessment is a manual handling assessment that nursing staff are required to complete at the same time as the falls risk assessment. The manual handling form stipulates how a patient should mobilise in light of their falls risk factors. So the two, in practice, are considered alongside each other. The manual handling form is more detailed in regards to how patients can/should mobilise, and there is a question as to whether the patient, when walking, requires assistance with drips or attachments and this is to be taken into consideration when completing the assessment. In Mrs Bruton’s case she was assessed on 14 October 2022 as not being at risk of falls and her manual handling assessment noted her to be independent. The question around requiring assistance with drips or attachments when mobilising had not however been completed.
Page | 2
The information recorded in the manual handling assessment has not been designed to automatically feed into the falls risk assessment as this was considered to be a duplication of information in the patient record. The recommendation is that these assessments are looked at in combination not isolation.
Our electronic records system (PICS) incorporates multiple assessments/records that when looked at in combination provides detailed guidance / overview of a patient’s status in regards to falls and mobility risk. Staff should therefore always refer to, and consider the following in combination; the falls risk assessment, the manual handling assessment (that provides a more detailed account of what mobility needs the patient has, such as attachments that may limit a person’s mobility, whether any specific mobility aids are required, and what level of supervision from staff is needed); also the Daily Care Plan, which details whether bed rails are required, any additional needs a person may have, and also demonstrates what their current needs are during that particular shift.
Updates to falls risk assessment document We have considered the concerns you have raised within your report to prevent future deaths and we are taking steps to add in a drop down menu, within the falls risk assessment, which will allow staff to select an appropriate option if a patient has any equipment, such as drains, in place. This will then also be recorded in the PHAF (Patient Handling Assessment Form) therefore attachments will be reflected in both risk assessments. This will further increase staff awareness of falls risk factors. There is a lead in time for the changes to be made to our PICS system, and we can confirm that this change is expected to take place on the 15th August 2023. In the meantime whilst waiting for the programming work to be completed, the Lead Nurse for Falls Prevention has attended and highlighted at Divisional Preventing Harm Groups, which are attended by ward managers, Matrons and Deputy Directors of Nursing, the importance of ensuring that attachments are recorded and considered as part of a person’s manual handling needs. This has also been discussed at the Operational Care Quality Group chaired by the Director of Nursing Quality, Safety and Innovation, and attended by all of the Divisional Deputy Directors of Nursing and Nursing Leads for patient harm groups. We have also updated our Trust Inpatient Falls Procedure so that this is further emphasised. Based on the review of our falls risk assessment and the updates we are making to PICS, we are confident that the systems and processes that we have in place are sufficient to minimise and manage the risk of falls of our patients.
I would like to assure you that the concerns raised within the Regulation 28 Report have been taken extremely seriously which I hope is demonstrated by our response above.
Sent To
- University Hospitals Birmingham NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
14 Jul 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 3 November 2022 I commenced an investigation into the death of Norma Winifred BRUTON. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Natural causes contributed to by injuries sustained in a fall.
Circumstances of the Death
The deceased was admitted to Birmingham Heartlands Hospital on 13 October 2022 for treatment of a pneumothorax with a background of pulmonary mycobacterium infection and chronic obstructive lung disease. An assessment of her risk of falling did not take into account the presence of a chest drain and an intravenous drip and Mrs Bruton was assessed as being able to mobilise independently. She had an unwitnessed fall on the morning of 15 October 2022 when trying to walk the short distance to her bathroom and sustained a right fractured neck of femur for which she underwent surgery on 20 October 2022. Mrs Bruton's condition deteriorated after the surgery and she died in hospital on 22 October 2022. Based on information from the Deceased's treating clinicians the medical cause of death was determined to be: 1a Sepsis 1b Hospital acquired pneumonia 1c II Chronic Obstructive Lung Disease, Frailty, Neck of femur fracture (operated), Pneumothorax CORONER'S CONCERNS During the course of 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 Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions.
2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls.
3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment.
1. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions.
2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls.
3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.