UK Inquiry Tracker

Joan Wright

PFD Report All Responded Ref: 2021-0420

Date of Report 17 December 2021

Coroner Catherine Cundy

Coroner Area Manchester West

Response Deadline est. 11 February 2022

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 11 Feb 2022

Coroner's Concerns (AI summary)

Insufficient and unreliable IT facilities hinder timely electronic record-keeping, forcing staff to rely on memory or paper notes, which results in unrecorded or omitted crucial clinical information.

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(1) Both the Divisional Review Report produced by the Trust and oral evidence at the inquest disclosed problems with insufficient workable IT facilities at the hospital to allow for timely record-keeping in patients' electronic notes. I was advised that all clinical staff are supposed to make records in the electronic notes and that no handwritten records are now kept. I heard evidence that staff therefore have to rely on memory, or notes written on scraps of paper, until such time as they can access the electronic records on a computer. This case provided several instances in the care of a single patient where either no notes were made at all of clinical discussions or management plans, or crucial information was omitted. I am concerned that the issues of availability, workability and accessibility of IT equipment for such recording (in the context of a reliance on paperless working) creates a risk of future deaths to other patients where crucial information mav QO unrecorded. 6-l ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 I YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11th FEBRARY 2021. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 81 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons - the deceased's son and daughter. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. J~~:/;~ 17 DECEMBER 2021 2

Responses

Royal Bolton Hospital NHS / Health Body

11 Feb 2022

Action Taken
The Informatics Team is conducting ward spot audits to monitor IT equipment, a topic discussed at Ward Managers meetings in December 2021 and January 2022. A Steering Group was established to review ward round processes and competing demands on IT equipment, with expected completion by May 2022. Agency staff also now receive training on the EPR system before booking shifts. (AI summary)

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Dear Ms Cundy, Re: Joan Wright - Regulation 28 Report to Prevent Future Deaths I am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued on 17th December 2021 following the inquest touching the death of Joan Wright on 15th December 2021 . May I take this opportunity to extend my sincere condolences to the family of Mrs Wright for their loss and appreciate this will still be a very difficult time for the family. I note that prior to the inquest hearing, you were provided with an Investigation Report, which had been undertaken by our Anaesthetics and Surgical Division. This report confirmed that a number of actions in relation to the identified care and service delivery concerns had already been taken by the Trust. I fully support the use of Regulation 28 Reports as an important mechanism for learning. I am grateful to you for sharing your concerns that our investigation did not satisfactorily address the factors associated with the availability and accessibility of Information Technology (IT) equipment. Following receipt of the Regulation 28 Report, our Informatics Team were asked to review the matters detailed in your report. I am now in a position to respond to your concerns as outlined in Section 5.

ilision Openness lr11~Jnt Compassion Excellence r~1:b1 Bolton NHS Foundation Trust Section 5 (1-)---------------------------- 1 am very sorry to learn that during the course of establishing how Mrs Wright came about her death you heard evidence that there were insufficient workable information technology facilities to enable contemporaneous documentation to be made on the wards. The Electronic Patient Record (EPR) system was deployed to inpatient areas in October 2019. The devices were allocated based on learning from other organisations, workflows, number of beds, ward layout, EPR functionality and existing equipment. The devices included; mobile computer carts, fixed desktop computers, drug trolley laptops, tablets and 'Patient Status at a Glance' electronic 'tracking boards'. This technology was approved by each of our Divisional Leadership Teams and through the governance of the Transformation Board prior to going live with the system. Following feedback from clinical staff, around their challenges in accessing the EPR system and associated devices, a working group was established to understand this further. This led to a test trial, which ran throughout May and June 2021, and aimed to consider the impact of supplying an additional two computers on wheels to inpatient wards. Findings, clearly demonstrated the positive impact these additional devices had in supporting staff with inputting timely, and maintaining accurate clinical records. The results were presented to the Senior Nurse Management Team in July 2021 and the Divisional Nurse Directors confirmed the device requirements. In August 2021, Executive approval of the recommendations for additional computers was provided. Following this, in October 2021 , a business case, outlining the plan for finance provision and information technology deployment, was approved by the Trusts Capital Revenue Investment Group. An order was placed with suppliers on the 11th November 2021 and since then there has been regular liaison with suppliers in order to secure the earliest available delivery of equipment. Due to the current global shortage of data silicon chips, which is severely affecting the manufacturing of technical equipment, this has delayed delivery of the order. The suppliers have provided a provisional delivery date of June 2022, however this is reliant upon no further delays within the manufacturing and distribution chain. Once the equipment has been delivered the Technical Team will prioritise resources to build and deploy the equipment across all wards, within seven to ten days. In addition, following the scoping of existing devices on wards, the Technical Team found that poor care of the equipment and the delay in reporting damaged equipment to the Information Technology Department resulted in avoidable equipment unavailability. In order to address this, the wider Informatics Team are undertaking regular ward visits to support and educate the clinical staff around good housekeeping of the equipment. Wards are held to account and have the responsibility of ensuring the equipment supplied is adequately cared for, batteries for the portable equipment is charged overnight in readiness for ward rounds and that any malfunctioning equipment is reported in a timely manner. The Technical Team will be undertaking ward spot audits when attending those areas to monitor this. This was raised and discussed at the Ward Managers and Matrons meeting held in December 2021 and January 2022. As a Trust we have a Transformation and Digital Board which tracks and monitors all developments within the Informatics and Technology Teams including the business case for the supply and upgrading of equipment on Wards.

1/ision O~nness h tt?yrll Compassion Excellence
r.•t:ki Bolton NHS Foundation Trust We acknowledge there have been pressures on IT equipment and the computers on wheels, in particular acrossihe-surgical wards;-where-u1ere1Tave1>een-c-ompet1ng demamts-trom"lhe--surgicattearrrs-and nursing staff. In addition to the extra equipment ordered, a Steering Group has been established to review ward round processes and the competing demands on the equipment by various clinical staff. The work being undertaken by the Steering Group is expected to be completed by May 2022 with relevant action plans developed and in place. Finally, I am also advised that you raised a further concern regarding the EPR system at an inquest into the death of . I understand this concern related to the training that agency staff receive on EPR. The Workforce Deployment Team, who work closely with a number of agencies, have provided assurance that once a prospective member of agency staff is approved to work with the Trust a link is provided to the agency staff that enables them to undertake training on the EPR system. Once this is completed, the agency staff are then permitted to book shifts with the Trust. A separate letter to the family of will be sent as agreed. I hope that the response from Bolton NHS Foundation Trust has provided you with the assurance that we have taken appropriate action to mitigate the risk of future deaths. Please do not hesitate to contact me in the event you require any further assistance.

Part of a Series

2 separate reports were issued from this inquest, each sent to different organisations.

2018-0408
Sent to: Department of Health and Social Care

All responded

This report (2021-0420) is shown above.

Sent To

Royal Bolton Hospital

Response Status

Linked responses 1 of 1

56-Day Deadline 11 Feb 2022

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

Circumstances of the Death

On the 27th of February 2021 the deceased fell at her home address. She was admitted to the Royal Bolton r-fospital the same day and diagnosed with a fractured left neck of femur. She undeiwent dynamic hip screw fixation on the 28th of February 2021, during which a guide wire was noted to have advanced through the pelvis and into the abdomen. No record was made of this complication in the operation note and the occurrence was not flagged with medical or nursing staff or with the deceased's family. On the 9th of March 2021 , a blood test showed the deceased had a raised mar1<er of infection. \Nhile the infection mar1<er dipped slightly on the 10th of March 2021, it remained high thereafter. On the 19th of March 2021 the wound discharged a high volume of purulent fluid which contained colifonn bacteria. On the balance of probabilities this infection was introduced into the wound by the guide wire which had penetrated her pelvis during surgery. The deceased undeiwent two surgical washouts of the wound on the 19th and the 22nd of March 2021and was commenced on antibiotics. It was not until this point that the wider treating team became aware of the guide wire penetration that had occurred on the 28th of February 2021 . The deceased remained an in-patient at the hospital until the 30th of April 2021 when she was discharged to a nursing home on intravenous antibiotics. Following a deterioration in her condition she was readmitted to the Royal Bolton Hospital as an emergency on the 30th of May 2021 where she was treated for suspected pneumonia before being discharged again to the nursing home on the 9th of June 2021 . Her condition con~inued to deteriorate and she died at the nursing home on the 16th of June 2021 .