Anne Harper
PFD Report
All Responded
Ref: 2021-0174
All 1 response received
· Deadline: 9 Apr 2021
Coroner's Concerns (AI summary)
The Major Trauma Centre lacks a major trauma lead consultant and trauma co-ordinator, which is contrary to NICE guidelines and has been an unresolved issue since at least 2018.
View full coroner's concerns
1. I heard evidence that a Major Trauma Centre is expected to have a major trauma lead consultant, and a trauma co-ordinator (in accordance with NICE guidelines). I understand that the Trust does not have these posts and that this has been the position since at least 2018.
Responses
Action Taken
The OUH has approved 2 additional WTE Rehabilitation Coordinator posts, increasing the number of WTE coordinators to 4 to provide a comprehensive 5 day service. Changes in protocols for the management of pain in chest injuries have also been established. (AI summary)
The OUH has approved 2 additional WTE Rehabilitation Coordinator posts, increasing the number of WTE coordinators to 4 to provide a comprehensive 5 day service. Changes in protocols for the management of pain in chest injuries have also been established. (AI summary)
View full response
Dear Ms Brannigan Regulation 28 Report Prevention of Future Deaths Inquest into the death of Mrs Anne Patricia Harper Thank you for your letter dated 12th February 2021 with the enclosed Prevention of Future Death Report: Iam sorry that it was necessary to write to the Trust in this regard: We note that the matter of concern you have raised is: "Iheard evidence that a Major Trauma Centre is expected to have a major trauma lead consultant, and a trauma cO-ordinator (In accordance with NICE Guidelines): I understand that the Trust does not have these posts and that this has been the position since at least 2018. We have reviewed the raised by your report and have documented our response below: Major Trauma Consultant and Co-ordinator posts are part of the provision of major trauma care within a Major Trauma Centre (MTC) and form part of the annual assessment performed by NHS England (NHSE) into Major Trauma Centres These reviews are self-assessed annually and by visiting committee 3 years (prior to the Covid-19 pandemic)_ Major Trauma Centres are also by NICE (Guidelines 39 and 40). NICE guideline 40 relates to service delivery in major trauma and raises the roles of Major Trauma Consultant and trauma coordinator. Heading 1.6.2 in the guidance states that a MTC should have a dedicated trauma ward for patients with multisystem injuries It also requires a designated consultant that is available to contact 24 hours a day, 7 week who has responsibility and authority for Way points every guided days
the hospital trauma service and leads the multidisciplinary team care. At the OUH there is a Trauma Orthopaedic Consultant available 24 hours a That consultant can lead on the involvement of any other staff required. In the OUH, the Major Trauma Consultant role has been undertaken by the Orthopaedic Trauma consultants since the inception of MTCs in 2012. The role as defined by NHSE requires consultant to undertake overall holistic care for all patients admitted to a MTC with traumatic injuries Although many patients do have orthopaedic injuries (either wholly or as part of multiple injuries) , there are other patients whose trauma is exclusively non-orthopaedic: This group is (for each speciality) a small number of patients. These patients have until now been managed by the surgical speciality related to their primary injury: The requirement for all major trauma patients to be initially managed by a single group of consultants has been difficult to implement because of the established successful model of care as described above This work has been ongoing since the last 'in person' peer review in 2018. We will redefine the current Orthopaedic Trauma consultants to that of the 'MTC Consultant' _ As the Trust moves to recover from the Covid-19 pandemic, we will relocate trauma services to clinical areas that are physically adjacent With this in place, patients would be admitted under the overall care of a 'Major Trauma Consultant' who will be an Orthopaedics consultant: If their trauma is exclusively related to a different surgical speciality, referral would be made to that speciality for ongoing lead care: If the has orthopaedic/ multiple (poly) trauma the would remain under the care of the MTC Consultant: Isolated traumatic brain injuries continue to be admitted under the care of neurosurgery. We would expect to retain some flexibility if a patient-specific factor required variation to this plan in order to ensure best care for the Iwish to reassure you and the Chief Coroner that all patients admitted to the OUH MTC have a lead consultant with the expertise to manage their injuries, and that the ward relocation of the MT service is a priority for us In respect of trauma coordinators; this role aims to allocate a named team member (keyworker) for each patient: Two roles are described by NHSE; 1) Trauma Coordinator (TC) and 2) Rehabilitation Coordinator (RC): Each MTC in England has chosen to build their service differently_ In Oxford, we currently have 1.4 whole time equivalent WTE) , Band 7 (senior) RCs who act as key workers for Major Trauma patients. Complete staffing of this group would require 6 WTE staff as identified by the Major Trauma management group in collaboration the incumbent staff. Since your letter, OUH has approved 2 additional WTE RC posts. This, will increase the number of WTE coordinators to 4 to provide comprehensive 5 days service: This staff group may be able to provide limited weekend cover butit is our expectation that 2 further will be added to deliver resilient working: As you described in your report, I do not feel that either of the reported concerns could have changed the sad outcome of Mrs Harper' $ case however we are committed to delivering change for future patients Furthermore, I would like to reiterate that changes in the protocols for management of in chest injuries have been established since your letter was received. day. patient patient will patient: with posts day pain
Ihope that this response provides assurance that the OUH is taking measures to address the issues you raised in your letter:
the hospital trauma service and leads the multidisciplinary team care. At the OUH there is a Trauma Orthopaedic Consultant available 24 hours a That consultant can lead on the involvement of any other staff required. In the OUH, the Major Trauma Consultant role has been undertaken by the Orthopaedic Trauma consultants since the inception of MTCs in 2012. The role as defined by NHSE requires consultant to undertake overall holistic care for all patients admitted to a MTC with traumatic injuries Although many patients do have orthopaedic injuries (either wholly or as part of multiple injuries) , there are other patients whose trauma is exclusively non-orthopaedic: This group is (for each speciality) a small number of patients. These patients have until now been managed by the surgical speciality related to their primary injury: The requirement for all major trauma patients to be initially managed by a single group of consultants has been difficult to implement because of the established successful model of care as described above This work has been ongoing since the last 'in person' peer review in 2018. We will redefine the current Orthopaedic Trauma consultants to that of the 'MTC Consultant' _ As the Trust moves to recover from the Covid-19 pandemic, we will relocate trauma services to clinical areas that are physically adjacent With this in place, patients would be admitted under the overall care of a 'Major Trauma Consultant' who will be an Orthopaedics consultant: If their trauma is exclusively related to a different surgical speciality, referral would be made to that speciality for ongoing lead care: If the has orthopaedic/ multiple (poly) trauma the would remain under the care of the MTC Consultant: Isolated traumatic brain injuries continue to be admitted under the care of neurosurgery. We would expect to retain some flexibility if a patient-specific factor required variation to this plan in order to ensure best care for the Iwish to reassure you and the Chief Coroner that all patients admitted to the OUH MTC have a lead consultant with the expertise to manage their injuries, and that the ward relocation of the MT service is a priority for us In respect of trauma coordinators; this role aims to allocate a named team member (keyworker) for each patient: Two roles are described by NHSE; 1) Trauma Coordinator (TC) and 2) Rehabilitation Coordinator (RC): Each MTC in England has chosen to build their service differently_ In Oxford, we currently have 1.4 whole time equivalent WTE) , Band 7 (senior) RCs who act as key workers for Major Trauma patients. Complete staffing of this group would require 6 WTE staff as identified by the Major Trauma management group in collaboration the incumbent staff. Since your letter, OUH has approved 2 additional WTE RC posts. This, will increase the number of WTE coordinators to 4 to provide comprehensive 5 days service: This staff group may be able to provide limited weekend cover butit is our expectation that 2 further will be added to deliver resilient working: As you described in your report, I do not feel that either of the reported concerns could have changed the sad outcome of Mrs Harper' $ case however we are committed to delivering change for future patients Furthermore, I would like to reiterate that changes in the protocols for management of in chest injuries have been established since your letter was received. day. patient patient will patient: with posts day pain
Ihope that this response provides assurance that the OUH is taking measures to address the issues you raised in your letter:
Sent To
- Oxford University Hospitals NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
9 Apr 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 22 September 2020 I opened an inquest into the death of Mrs Anne Patricia Harper, aged 78. The investigation concluded at the end of the inquest on 10 February 2021.
The medical cause of death was:
Ia Respiratory Failure Ib Rib Fractures with flail segments
II Right pneumothorax, Interstitial Lung Disease, Spinal Fractures, Rheumatoid Arthritis, Hiatus Hernia
Mrs Harper fell down the stairs at her home in the night on 13 September 2020. She was taken to A&E at the John Radcliffe Hospital, arriving at 2.15am on 14 September 2020. Due to her fragility and osteoporosis, she suffered extensive fractures. This included flail fractures of 10 of her ribs, her pelvis, clavicle, forearm and spine. She remained in A&E until 6.40pm. She developed respiratory failure and died at the hospital at 22.17hrs that evening.
Conclusion: Accidental death.
The medical cause of death was:
Ia Respiratory Failure Ib Rib Fractures with flail segments
II Right pneumothorax, Interstitial Lung Disease, Spinal Fractures, Rheumatoid Arthritis, Hiatus Hernia
Mrs Harper fell down the stairs at her home in the night on 13 September 2020. She was taken to A&E at the John Radcliffe Hospital, arriving at 2.15am on 14 September 2020. Due to her fragility and osteoporosis, she suffered extensive fractures. This included flail fractures of 10 of her ribs, her pelvis, clavicle, forearm and spine. She remained in A&E until 6.40pm. She developed respiratory failure and died at the hospital at 22.17hrs that evening.
Conclusion: Accidental death.
Circumstances of the Death
The severe fractures injuries were caused by a fall down the stairs at home, on a background of severe co-morbidities, a history of previous fractures and osteoporosis.
The inquest today also explored the hospital care. Both of the NHS consultants gave candid evidence to the court about the care in the John Radcliffe Hospital on 14 September 2020. I note that this was during the Covid-19 pandemic which will have increased demand on the NHS services. I thank them for their written statements and their oral evidence, including the structured judgment review. I understand that the Trust decided that this case does not meet the threshold for a 'serious incident' investigation. The care was described, in places, as substandard, unsatisfactory and poor.
I accept the evidence given to me, that;
1. There was no trauma call, which would have resulted in consultant lead care in A&E, and a CT scan within 1 hour. In fact, the extremely serious injuries were underestimated and a CT scan was not performed until 3 hours after attendance. As a result, there was no team which 'owned' Mrs Harper for quite some time.
2. Mrs Harper remained in A&E for a long time. She arrived at 2.15am, and was not transferred to a ward until around 5.30pm, when she deteriorated. Because of the Covid-19 pandemic restrictions, her family were not allowed to be with her.
3. An MRI was performed in the afternoon. I heard that the purpose of this was unclear, because it was unlikely to change the plan for her care.
4. No observations were recorded for around 6 hours between 11.10am and 5.20pm. I heard that she would have been connected to an oxygen monitor.
5. The prognosis could have been identified in the morning, once the results of the CT scans were known. Each specialty attended to review her, but I heard that the overview and co-ordination of her care was missing. The end of life decision was not made until she arrived on a ward in the evening. As a result, her Son and other family members were not informed, so could not be with her before she died.
6. In relation to analgesia, I heard that her injuries were causing her pain when the paramedic attended (Entonox and 10mg of morphine was given). From the time of her arrival in hospital, until her death 20 hours later, she was given a total of 2g paracetamol and 2.5mg IV morphine. Her pain score was not properly recorded. Between midday and 5.20pm no analgesia was administered and no physiological observations were recorded during this time. I accept the evidence that if she had been on a ward at this time, instead of in in A&E, her analgesia would have been likely to have been better managed. I accept the evidence from the doctor; that the analgesia administered was likely to be insufficient.
7. The trauma consultant sought regional analgesia (in accordance with policy), but because there were no ICU bed, ward bed or anaesthetists available (which I heard is not uncommon), this could not be administered. The Pain Team later confirmed that they could not attend in A&E. There was no adequate alternative plan made for analgesia. I accept that from the point at which Mrs Harper fell and sustained extensive and severe injuries, it was unlikely that she would survive. The only real option, after investigation, was to make her comfortable using a regional block and/or other analgesia. I heard that Mrs Harper was only able to take shallow breaths due to the pain. I asked about the relationship between the multiple flailing rib fractures, the insufficient analgesia and her eventual respiratory failure. The medical evidence from the anaesthetist was that a regional block would not have been sufficient in any event, given the extent of the damage to the rib cage, and that adequate analgesia would have been unlikely to have avoided the respiratory failure and death occurring when it did.
The Trust gave evidence that action has been taken since this death to improve in some of the areas identified above, including that;
1. The Pain Team can now attend in A&E
2. The Trust policy on management of blunt chest trauma has been updated, so that if/when regional anaesthesia is not available immediately, that an alternative plan for analgesia is clear, which may include a patient controlled anaesthesia (PCA).
The inquest today also explored the hospital care. Both of the NHS consultants gave candid evidence to the court about the care in the John Radcliffe Hospital on 14 September 2020. I note that this was during the Covid-19 pandemic which will have increased demand on the NHS services. I thank them for their written statements and their oral evidence, including the structured judgment review. I understand that the Trust decided that this case does not meet the threshold for a 'serious incident' investigation. The care was described, in places, as substandard, unsatisfactory and poor.
I accept the evidence given to me, that;
1. There was no trauma call, which would have resulted in consultant lead care in A&E, and a CT scan within 1 hour. In fact, the extremely serious injuries were underestimated and a CT scan was not performed until 3 hours after attendance. As a result, there was no team which 'owned' Mrs Harper for quite some time.
2. Mrs Harper remained in A&E for a long time. She arrived at 2.15am, and was not transferred to a ward until around 5.30pm, when she deteriorated. Because of the Covid-19 pandemic restrictions, her family were not allowed to be with her.
3. An MRI was performed in the afternoon. I heard that the purpose of this was unclear, because it was unlikely to change the plan for her care.
4. No observations were recorded for around 6 hours between 11.10am and 5.20pm. I heard that she would have been connected to an oxygen monitor.
5. The prognosis could have been identified in the morning, once the results of the CT scans were known. Each specialty attended to review her, but I heard that the overview and co-ordination of her care was missing. The end of life decision was not made until she arrived on a ward in the evening. As a result, her Son and other family members were not informed, so could not be with her before she died.
6. In relation to analgesia, I heard that her injuries were causing her pain when the paramedic attended (Entonox and 10mg of morphine was given). From the time of her arrival in hospital, until her death 20 hours later, she was given a total of 2g paracetamol and 2.5mg IV morphine. Her pain score was not properly recorded. Between midday and 5.20pm no analgesia was administered and no physiological observations were recorded during this time. I accept the evidence that if she had been on a ward at this time, instead of in in A&E, her analgesia would have been likely to have been better managed. I accept the evidence from the doctor; that the analgesia administered was likely to be insufficient.
7. The trauma consultant sought regional analgesia (in accordance with policy), but because there were no ICU bed, ward bed or anaesthetists available (which I heard is not uncommon), this could not be administered. The Pain Team later confirmed that they could not attend in A&E. There was no adequate alternative plan made for analgesia. I accept that from the point at which Mrs Harper fell and sustained extensive and severe injuries, it was unlikely that she would survive. The only real option, after investigation, was to make her comfortable using a regional block and/or other analgesia. I heard that Mrs Harper was only able to take shallow breaths due to the pain. I asked about the relationship between the multiple flailing rib fractures, the insufficient analgesia and her eventual respiratory failure. The medical evidence from the anaesthetist was that a regional block would not have been sufficient in any event, given the extent of the damage to the rib cage, and that adequate analgesia would have been unlikely to have avoided the respiratory failure and death occurring when it did.
The Trust gave evidence that action has been taken since this death to improve in some of the areas identified above, including that;
1. The Pain Team can now attend in A&E
2. The Trust policy on management of blunt chest trauma has been updated, so that if/when regional anaesthesia is not available immediately, that an alternative plan for analgesia is clear, which may include a patient controlled anaesthesia (PCA).
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