Norma Rushworth
PFD Report
All Responded
Ref: 2021-0278
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
All 2 responses received
· Deadline: 18 Oct 2021
Coroner's Concerns (AI summary)
Pandemic restrictions led to inadequate support for a vulnerable patient in outpatient settings and limited post-discharge monitoring, hindering accurate assessment and timely recognition of deteriorating health.
View full coroner's concerns
1. The inquest heard that due to the pandemic and restrictions Mrs Rushworth was not supported as she would usually have been at outpatient appointments. The inquest heard that this impacted significantly on the quality of the history available to clinicians; support for a vulnerable patient and her decision making.
2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage.
2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage.
Responses
Action Planned
Greater Manchester Health and Social Care Partnership will present learning from the case to the Greater Manchester Quality Board, communicate advice and guidance to relevant providers, and share learning through governance and learning forums. (AI summary)
Greater Manchester Health and Social Care Partnership will present learning from the case to the Greater Manchester Quality Board, communicate advice and guidance to relevant providers, and share learning through governance and learning forums. (AI summary)
View full response
Dear Ms Mutch
Re: Regulation 28 Report to Prevent Future Deaths – Norma Rushworth 10/10/20
Thank you for your Regulation 28 Report dated 23/08/21 concerning the sad death of Norma Rushworth on 10/10/20. Firstly, I would like to express my deep condolences to Norma Rushworth’s family.
The inquest concluded that Norma’s death was a result of 1a Bronchopneumonia, 1b Immobilisation following surgery for Diverticulitis, 1c II Ischaemic Heart Disease, Aortic Valve Disease, Hypertensive disease.
Following the inquest you raised concerns in your Regulation 28 Report to Greater Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future deaths will occur unless action is taken.
This letter addresses the issues that fall within the remit of GMHSCP and how we can share the learning from this case.
Point 1 – support for vulnerable patients at appointments during the pandemic. At the time of Mrs Rushworth’s death, hospital trusts were constrained by the national guidance around attendance at hospital settings “Visiting healthcare settings during COVID-19 pandemic.” The guidance restricted patients from attending appointments with a person to support them. In March 2021 this guidance was updated to advise that patients attending outpatients, diagnostic service and Emergency Departments are now allowed to be accompanied by one person to support them with making complex/difficult decisions. A link to the full guidance is included below for information:
Coronavirus » Visiting healthcare inpatient settings during the COVID-19 pandemic (england.nhs.uk)
Point 2. Communication between acute and community settings on risk and patient management. Mrs Rushworth was discharged from the acute trust on 9th September following good post-operative recovery. District nurses attended Mrs Rushworth the day after her discharge from the acute trust. They then attended on 3 additional days, with the final attendance being to remove her stitches on 16th September, with this date being scheduled by the consultant. Mrs Rushworth’s attended A&E on the 17th September after the wound reopened. Actions taken or being taken to prevent reoccurrence across Greater Manchester.
1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.
2. Communication to all relevant providers to share appropriate advice and guidance and increase staff awareness regarding the range of materials that are already available.
3. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums.
In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. GMHSCP is committed to improving outcomes for the population of Greater Manchester.
I hope this response provides the relevant assurances you require. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – Norma Rushworth 10/10/20
Thank you for your Regulation 28 Report dated 23/08/21 concerning the sad death of Norma Rushworth on 10/10/20. Firstly, I would like to express my deep condolences to Norma Rushworth’s family.
The inquest concluded that Norma’s death was a result of 1a Bronchopneumonia, 1b Immobilisation following surgery for Diverticulitis, 1c II Ischaemic Heart Disease, Aortic Valve Disease, Hypertensive disease.
Following the inquest you raised concerns in your Regulation 28 Report to Greater Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future deaths will occur unless action is taken.
This letter addresses the issues that fall within the remit of GMHSCP and how we can share the learning from this case.
Point 1 – support for vulnerable patients at appointments during the pandemic. At the time of Mrs Rushworth’s death, hospital trusts were constrained by the national guidance around attendance at hospital settings “Visiting healthcare settings during COVID-19 pandemic.” The guidance restricted patients from attending appointments with a person to support them. In March 2021 this guidance was updated to advise that patients attending outpatients, diagnostic service and Emergency Departments are now allowed to be accompanied by one person to support them with making complex/difficult decisions. A link to the full guidance is included below for information:
Coronavirus » Visiting healthcare inpatient settings during the COVID-19 pandemic (england.nhs.uk)
Point 2. Communication between acute and community settings on risk and patient management. Mrs Rushworth was discharged from the acute trust on 9th September following good post-operative recovery. District nurses attended Mrs Rushworth the day after her discharge from the acute trust. They then attended on 3 additional days, with the final attendance being to remove her stitches on 16th September, with this date being scheduled by the consultant. Mrs Rushworth’s attended A&E on the 17th September after the wound reopened. Actions taken or being taken to prevent reoccurrence across Greater Manchester.
1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.
2. Communication to all relevant providers to share appropriate advice and guidance and increase staff awareness regarding the range of materials that are already available.
3. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums.
In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. GMHSCP is committed to improving outcomes for the population of Greater Manchester.
I hope this response provides the relevant assurances you require. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Noted
NHS England expresses condolences, acknowledges the concerns, and highlights national guidance and resources for wound care and remote consultations, including the National Wound Care Strategy Programme. (AI summary)
NHS England expresses condolences, acknowledges the concerns, and highlights national guidance and resources for wound care and remote consultations, including the National Wound Care Strategy Programme. (AI summary)
View full response
Dear Ms Mutch,
Re: Regulation 28 Report to Prevent Future Deaths – Norma Rushworth 14th October 2020
Thank you for your Regulation 28 Report dated 13th May 2021 concerning the death of Norma Rushworth on 14th October 2020. Firstly, I would like to express my deep condolences to Norma Rushworth’s family.
Please accept our apologies for the length of time this response has taken to complete. The regulation 28 report concludes Norma Rushworth’s death was a result of complications of emergency surgery following a previous surgical procedure that had resulted in an abdominal dehiscence due in part to a wound infection not identified prior to the abdominal dehiscence.
With the medical cause of death as result of 1a Bronchopneumonia 1b Immobilisation following surgery for Diverticulitis 1c II Ischaemic Heart Disease, Aortic Valve Disease, Hypertensive Disease.
Following the inquest you raised concerns in your Regulation 28 Report to NHS England.
The matters of concern are as follows:
1. The inquest heard that due to the pandemic and restrictions Mrs Rushworth was not supported as she would usually have been at outpatient appointments. The inquest heard that this impacted significantly on the quality of the history available to clinicians; support for a vulnerable patient and her decision making.
National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH
16th June 2022
2. The inquest heard that following her discharge back into the community after surgery, support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly enough to the community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result, recognised at an early stage.
In response to the first query I refer to the Greater Manchester Health and Social Care Partnership (GMHCSP) response which stated that at the time of Mrs Rushworth’s death, the national guidance around attendance at hospital settings “Visiting healthcare settings during COVID-19 pandemic” restricted patients from attending appointments with a person to support them. In March 2021 this guidance was updated to advise that patients attending outpatients, diagnostic service and Emergency Departments are now allowed to be accompanied by one person to support them with making complex/difficult decisions. A link to the full guidance is included for information: Coronavirus » Visiting healthcare inpatient settings during the COVID-19 pandemic (england.nhs.uk). The visiting guidance was reviewed regularly during the pandemic.
With regards the second matter of concern In terms of national discharge policy in place in October 2020, this included a clear set of agreed criteria to reside, which provide a framework to guide clinical staff as to whether a person is fit to be discharged or should remain in hospital for further treatment. The guidance advises that patients are reviewed against these criteria on a daily basis. The guidance also provided information on how health and social care staff should engage with patients and carers ahead of discharge. Section 6 of the current version of the guidance summarises the actions and support that should be provided. Hospital discharge service guidance - GOV.UK (www.gov.uk) As the cause of death documented in the report also refers to wound infection, we would also like to highlight to you that in 2018 NHSEI commissioned The National Wound Care Strategy Programme, a long-term commitment to improving wound care. The aim of the England-wide strategy is to improve the quality of chronic wound care through innovative solutions that will improve wound healing and prevent harm in line with the commitments set out in the NHS Long Term Plan. The Programme aims to standardise wound care by developing clinical recommendations which support excellence in preventing, assessing, and treating people with wounds to optimise healing and minimise the burden of wounds for patients, carers and health and care providers.
The recommendations of the National Wound Care Strategy Programme are available online and have been widely publicised to the clinical community. In addition, the Programme and Health Education England (HEE) have published free to access, online education on a number of wound care topics, and continue to develop further wound care education resources. These resources are aimed
primarily at registered clinicians and experienced health and care support staff but the NWCSP is also contributing to the work of the NHS England and Improvement Enhancing Health in Care Homes team which is developing similar resources for novice health and care support staff. Work is also underway to support Higher Education Institutions that provide pre-registration clinical education in providing wound care education of an appropriate standard and range in their pre-registration programmes.
The learning from the PFD has been shared with all NHS England and Improvement regions.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – Norma Rushworth 14th October 2020
Thank you for your Regulation 28 Report dated 13th May 2021 concerning the death of Norma Rushworth on 14th October 2020. Firstly, I would like to express my deep condolences to Norma Rushworth’s family.
Please accept our apologies for the length of time this response has taken to complete. The regulation 28 report concludes Norma Rushworth’s death was a result of complications of emergency surgery following a previous surgical procedure that had resulted in an abdominal dehiscence due in part to a wound infection not identified prior to the abdominal dehiscence.
With the medical cause of death as result of 1a Bronchopneumonia 1b Immobilisation following surgery for Diverticulitis 1c II Ischaemic Heart Disease, Aortic Valve Disease, Hypertensive Disease.
Following the inquest you raised concerns in your Regulation 28 Report to NHS England.
The matters of concern are as follows:
1. The inquest heard that due to the pandemic and restrictions Mrs Rushworth was not supported as she would usually have been at outpatient appointments. The inquest heard that this impacted significantly on the quality of the history available to clinicians; support for a vulnerable patient and her decision making.
National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH
16th June 2022
2. The inquest heard that following her discharge back into the community after surgery, support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly enough to the community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result, recognised at an early stage.
In response to the first query I refer to the Greater Manchester Health and Social Care Partnership (GMHCSP) response which stated that at the time of Mrs Rushworth’s death, the national guidance around attendance at hospital settings “Visiting healthcare settings during COVID-19 pandemic” restricted patients from attending appointments with a person to support them. In March 2021 this guidance was updated to advise that patients attending outpatients, diagnostic service and Emergency Departments are now allowed to be accompanied by one person to support them with making complex/difficult decisions. A link to the full guidance is included for information: Coronavirus » Visiting healthcare inpatient settings during the COVID-19 pandemic (england.nhs.uk). The visiting guidance was reviewed regularly during the pandemic.
With regards the second matter of concern In terms of national discharge policy in place in October 2020, this included a clear set of agreed criteria to reside, which provide a framework to guide clinical staff as to whether a person is fit to be discharged or should remain in hospital for further treatment. The guidance advises that patients are reviewed against these criteria on a daily basis. The guidance also provided information on how health and social care staff should engage with patients and carers ahead of discharge. Section 6 of the current version of the guidance summarises the actions and support that should be provided. Hospital discharge service guidance - GOV.UK (www.gov.uk) As the cause of death documented in the report also refers to wound infection, we would also like to highlight to you that in 2018 NHSEI commissioned The National Wound Care Strategy Programme, a long-term commitment to improving wound care. The aim of the England-wide strategy is to improve the quality of chronic wound care through innovative solutions that will improve wound healing and prevent harm in line with the commitments set out in the NHS Long Term Plan. The Programme aims to standardise wound care by developing clinical recommendations which support excellence in preventing, assessing, and treating people with wounds to optimise healing and minimise the burden of wounds for patients, carers and health and care providers.
The recommendations of the National Wound Care Strategy Programme are available online and have been widely publicised to the clinical community. In addition, the Programme and Health Education England (HEE) have published free to access, online education on a number of wound care topics, and continue to develop further wound care education resources. These resources are aimed
primarily at registered clinicians and experienced health and care support staff but the NWCSP is also contributing to the work of the NHS England and Improvement Enhancing Health in Care Homes team which is developing similar resources for novice health and care support staff. Work is also underway to support Higher Education Institutions that provide pre-registration clinical education in providing wound care education of an appropriate standard and range in their pre-registration programmes.
The learning from the PFD has been shared with all NHS England and Improvement regions.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Sent To
- Greater Manchester Health and Social Care Partnership
- NHS England
Response Status
Linked responses
2 of 2
56-Day Deadline
18 Oct 2021
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 14th October 2020 I commenced an investigation into the death of Norma Rushworth. The investigation concluded on the 13th May 2021 and the conclusion was one of Narrative: Died from complications of emergency surgery following a previous surgical procedure that had resulted in an abdominal dehiscence due in part to a wound infection not identified prior to the abdominal dehiscence. The medical cause of death was 1a Bronchopneumonia 1b Immobilisation following surgery for Diverticulitis 1c II Ischaemic Heart Disease, Aortic Valve Disease, Hypertensive disease
Circumstances of the Death
Norma Rushworth was identified to have a narrowing of the sigmoid due to diverticulitis. She was operated on at Tameside General Hospital initially laparoscopically but then that was not viable through open surgery. The colon was resectioned. She was discharged home. Whilst at home she had an abdominal dehiscence and was admitted back to Tameside General Hospital where she was operated on as an emergency. The dehiscence had occurred as a result of an unidentified infection of the wound, her age and cardio vascular compromise. She developed a chest infection. She had a cardiac arrest when the central line was removed. She was resuscitated and transferred back to the Intensive Care Unit. She continued to deteriorate. On 10th October 2020 she died at Tameside General Hospital. Post mortem examination found she had died from bronchopneumonia with significant underlying heart disease contributing to her death.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Prevent discharge of hospitalised children with concerns until home is safe
Laming Inquiry
Care and discharge planning
Require consultant or paediatrician permission for discharging children with protection concerns.
Laming Inquiry
Care and discharge planning
Require documented future care plan for discharging children with protection concerns.
Laming Inquiry
Care and discharge planning
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.