Laura Booth
PFD Report
All Responded
Ref: 2021-0137
All 1 response received
· Deadline: 4 Jul 2021
Coroner's Concerns (AI summary)
Senior clinicians and staff displayed a grave lack of understanding and application of the Mental Capacity Act, with inadequate training leading to failures in best interests decision-making and patient/family involvement.
View full coroner's concerns
During the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.
(1) I heard evidence at the inquest about the changes which have been made in the Hospital to the nutrition services and I found these changes highly encouraging. I am now satisfied that there is an identified clinician with decision making responsibility in these circumstances. I am therefore not making recommendations which relate to the nutrition services within the hospital.
(2) I am satisfied and remain gravely concerned about the lack of knowledge, respect and application of the Mental Capacity Act principles amongst staff treating patients who may not have capacity to make decisions for themselves.
(3) Having heard evidence at the inquest I remain gravely concerned that Senior Clinicians have limited or no understanding of the Mental Capacity Act and apply it in a way which undermines the principles and requirements of the legislation.
(4) I have heard evidence of online training tools which have been undertaken; whilst some training is better than no training it is clear to me that this training is insufficient to embed, in practice, knowledge and understanding of the Mental Capacity Act in a way which protects the vulnerable people it is intended to serve.
(5) There appears to be a lack of understanding that decisions, when referred to in a best interests sense, are specific. This is not an overall catch all care plan. For example, the decision about whether Laura should receive an NG tube is one specific decision it is not bound up with ceilings of care decisions or any other decisions to be made with and for Laura.
(6) Laura was non verbal but she could communicate. There was no evidence of anyone seeking Laura's parents’ views in a way which would be compliant with the Mental Capacity Act and even more worryingly, no evidence of clinical teams seeking Laura's views at all.
(7) There was evidence in the clinical notes of one best interests form completed for Laura's admission for her eye surgery. The completion of this form, whilst a positive that it had been completed and is evidence that best interests had been considered, remains woefully inadequate in details and upon further exploration it was apparent that no attempt had been made to engage Laura in the decision making.
(8) There appeared to be a view that although there was no formal best interests meeting for decisions about Laura's nutrition, clinical discussions were taking place with the right clinicians and therefore the decisions would not be changed by a best interests meeting. This is a fundamental misunderstanding about the requirements of the Mental Capacity Act and best interests, clinical decisions are not a substitute for the individual being supported to decide for themselves or for a decision made in their best interests to be reflective of their own views. In the same way as an individual with capacity may decline a treatment or intervention, even where it is recommended by a clinician in the highest possible terms, a treatment or intervention can be declined on Ps behalf where that decision is made in their best interests in accordance with the requirements of the Mental Capacity Act. Where necessary this may require application to the Court of Protection where there is a dispute.
(9) I remain concerned that all staff treating Laura have expressed the view that they did not expect Laura to die in this admission and were very upset when she did. I am therefore at a loss as to why the verification of death form records her as being an expected death. I would therefore challenge the Trust to consider whether there is a need to reflect on the completion of these forms and their importance and likewise whether there is a need to reflect on presumptions made about an individual’s underlying health conditions when completing verification of death forms.
(10) I also remain concerned at a lack of understanding about the importance and relevance of Laura's hospital passport. This is a document which if read and understood by those treating Laura should mean that they can understand her, her communication style and her support needs so that she can be involved in decision making. It also should, if utilised properly, ensure that Laura's parents could have a level of reassurance that even if they were not there, Laura would be treated as if they were as staff would know how to communicate with Laura and understand what it was that she needed from them.
(1) I heard evidence at the inquest about the changes which have been made in the Hospital to the nutrition services and I found these changes highly encouraging. I am now satisfied that there is an identified clinician with decision making responsibility in these circumstances. I am therefore not making recommendations which relate to the nutrition services within the hospital.
(2) I am satisfied and remain gravely concerned about the lack of knowledge, respect and application of the Mental Capacity Act principles amongst staff treating patients who may not have capacity to make decisions for themselves.
(3) Having heard evidence at the inquest I remain gravely concerned that Senior Clinicians have limited or no understanding of the Mental Capacity Act and apply it in a way which undermines the principles and requirements of the legislation.
(4) I have heard evidence of online training tools which have been undertaken; whilst some training is better than no training it is clear to me that this training is insufficient to embed, in practice, knowledge and understanding of the Mental Capacity Act in a way which protects the vulnerable people it is intended to serve.
(5) There appears to be a lack of understanding that decisions, when referred to in a best interests sense, are specific. This is not an overall catch all care plan. For example, the decision about whether Laura should receive an NG tube is one specific decision it is not bound up with ceilings of care decisions or any other decisions to be made with and for Laura.
(6) Laura was non verbal but she could communicate. There was no evidence of anyone seeking Laura's parents’ views in a way which would be compliant with the Mental Capacity Act and even more worryingly, no evidence of clinical teams seeking Laura's views at all.
(7) There was evidence in the clinical notes of one best interests form completed for Laura's admission for her eye surgery. The completion of this form, whilst a positive that it had been completed and is evidence that best interests had been considered, remains woefully inadequate in details and upon further exploration it was apparent that no attempt had been made to engage Laura in the decision making.
(8) There appeared to be a view that although there was no formal best interests meeting for decisions about Laura's nutrition, clinical discussions were taking place with the right clinicians and therefore the decisions would not be changed by a best interests meeting. This is a fundamental misunderstanding about the requirements of the Mental Capacity Act and best interests, clinical decisions are not a substitute for the individual being supported to decide for themselves or for a decision made in their best interests to be reflective of their own views. In the same way as an individual with capacity may decline a treatment or intervention, even where it is recommended by a clinician in the highest possible terms, a treatment or intervention can be declined on Ps behalf where that decision is made in their best interests in accordance with the requirements of the Mental Capacity Act. Where necessary this may require application to the Court of Protection where there is a dispute.
(9) I remain concerned that all staff treating Laura have expressed the view that they did not expect Laura to die in this admission and were very upset when she did. I am therefore at a loss as to why the verification of death form records her as being an expected death. I would therefore challenge the Trust to consider whether there is a need to reflect on the completion of these forms and their importance and likewise whether there is a need to reflect on presumptions made about an individual’s underlying health conditions when completing verification of death forms.
(10) I also remain concerned at a lack of understanding about the importance and relevance of Laura's hospital passport. This is a document which if read and understood by those treating Laura should mean that they can understand her, her communication style and her support needs so that she can be involved in decision making. It also should, if utilised properly, ensure that Laura's parents could have a level of reassurance that even if they were not there, Laura would be treated as if they were as staff would know how to communicate with Laura and understand what it was that she needed from them.
Responses
Action Taken
The Trust has taken several actions to improve Mental Capacity Act (MCA) understanding, including enhanced MCA training, clearer documentation guidelines, and Health Passport promotion. They also reviewed the verification of death process and found the documentation to be accurate based on the patient's condition at the time of death. (AI summary)
The Trust has taken several actions to improve Mental Capacity Act (MCA) understanding, including enhanced MCA training, clearer documentation guidelines, and Health Passport promotion. They also reviewed the verification of death process and found the documentation to be accurate based on the patient's condition at the time of death. (AI summary)
View full response
Dear Ms Coombs
Prevention of Future Deaths Report – Laura Booth
I write to formally respond to your Prevention of Future Deaths (PFD) Report dated 5 May 2021, following the very sad death of Laura Booth. I wanted to say at the outset how saddened I am by Laura’s death and how sincerely sorry I am for the additional distress and upset the outstanding concerns you outline in your report have no doubt caused her parents. I truly hope that we can learn from this case and take actions to ensure as far as is possible that nothing similar happens again.
Firstly, I would like to thank you for acknowledging the progress we have made with regard to our nutrition services in response to this sad case.
I fully appreciate your concerns with regard to the knowledge and application of the requirements of the Mental Capacity Act (MCA) by the Trust’s clinicians, including; the understanding of best interest discussions; the need to engage the patient, family and carers in these discussions; and the need to fully document each and every time they occur. We acknowledge the lack of understanding by some of our staff with regard to the importance of Laura’s Health Passport, which, if it had been utilised correctly, would have ensured all staff understood her communication style, thereby supporting consistent involvement in decision-making.
Over the past few years the Trust has undertaken a wide range of actions to embed the requirements of the Mental Capacity Act (MCA) and ensure that there is proactive support for learning disability patients, and other patient groups who may lack full capacity. Prior to the Inquest into Laura’s death, we had started to give this area of work greater emphasis and the conclusions that you reached give further weight to the importance of this work, which includes: The development and delivery of training, which, as detailed later in this letter has now been strengthened to ensure all front-line clinical staff have the required knowledge. A range of resources for staff which are easily accessible via the Trust’s intranet site. These include clear and comprehensive guidance on the principles of the MCA, resources for raising staff awareness and contact details so that staff can access specialist support.
3
agreed to ensure the appropriate dissemination of information relating to MCA across relevant staff groups, in order to raise awareness.
In order to assess the impact of this training, the following measures have been put in place and are on-going: The current post-training evaluation will be replaced with a process of pre- and post- training assessment of learning to demonstrate increased knowledge. A programme of MCA/Best Interests audits commenced in June 2021, to examine the application of legislation in practice and to measure improvements post training. Clinical areas where poor compliance is identified will receive targeted training. Complaints will be analysed to identify any concerns relating to the application of MCA, which will be fed into the MCA steering group for action and into MCA staff training, where appropriate.
This training and the supporting resources will be further developed following the introduction of the Liberty Protection Safeguards in April 2022. The Trust has funded and is recruiting to a specialist team to support the implementation of this new process, which will further embed MCA processes and awareness across the organisation.
What action the Trust will take to ensure that senior clinicians are familiar with the provisions of the Mental Capacity Action and any subsequent legislation developed with the same aims and objectives and make this business as usual for those individuals and the junior doctors they supervise.
In addition to the mandatory training described above, additional training including workshops and master classes such as Assessing Mental Capacity are already available and bespoke training can be arranged, tailored to specific teams e.g. training on MCA/DoLS has recently been arranged with the senior clinical staff from Infectious Diseases, at their request.
We are committed to rolling out this more advanced training to all senior decision makers. This will initially be targeted at Clinical Directors who will then be tasked with deciding how best to deliver this within their directorates, which cover a wide variety of services. This approach will enable us to ensure training is tailored to the intended audience and that uptake is high. The progress of this advanced training will be monitored by the Mental Health Steering Group to ensure that all appropriate staff groups receive this training.
I also understand that you have kindly offered to deliver training and that you are meeting with Dr Deputy Medical Director to discuss the format of this training.
In addition, in order to ensure that we recruit staff with the appropriate skills and knowledge, questions relating to the understanding of the MCA and DoLS are being made available for use in interviews for senior clinicians.
How individuals who lack capacity will be supported to influence decisions about their own care as much as possible.
The need to ensure individuals who lack capacity are supported to influence decisions about their own care is explicit within the training described above, and is reflected in Trust documentation available for staff, including Best Interests Checklist and Best Interests Decision Record. These documents act as an aide memoire to guide staff through the best interests process and their use in practice is emphasised through the training process.
Resources to support patients with communication needs, such as the communication booklet, are available via the intranet and these, along with the Health Passport support staff to identify and respond to the communication needs of patients with a learning disability. In addition,
4
communication booklets have been given to each ward; further work is being undertaken to check that hard copies of the booklet are available in all areas and promote its use. The work to promote the use of the Health Passport is described in more detail later.
Reassuringly, in a recent survey of learning disability service users, run by the NHS Benchmarking Network, 84.2% of respondents felt staff explained things in a way they could understand (compared with 81.0% nationally) and 90.5% felt listened to (compared with 83.0% nationally).
How families are brought into these discussions where patients cannot make decisions for themselves and what measures are in/being brought into place to ensure that there is a clear audit trail of the thoughts and feelings of families and relatives.
The involvement of families is also reflected in the Best Interests Checklist and Best Interests Decision record, described above and there is clear guidance for staff about who must, where practicable, be included in consultation when deciding on best interests.
The importance of including family/advocates in decision making will continue to be made explicit in MCA training and the impact of this will be assessed, as described previously, through pre- and post-training evaluation of knowledge and audit of application in practice.
In the recent survey of learning disability service users, 94.4% of respondents felt staff listened to their family’s views (compared with 81.4% nationally).
What measures will be taken to ensure continuous compliance to both the practical application of the statutory regime as well as individual understanding of it.
As described previously, a programme of MCA/Best Interests audits commenced in June, to examine the application and recording of the MCA and Best Interests decision making process following the principles outlined in the MCA Code of Practice. The audit will include reviewing evidence of patient, family and/or advocate involvement and the use of the Health Passport. The results, which will be available in October 2021, will be used to identify clinical areas within the Trust requiring additional training and support.
Any breaches in lawful practice should be reported as an incident on Datix, by any member of staff. All such incidents are reviewed by the Specialist Advisor - MCA and DoL Safeguards and in future thematic analysis of these incidents will be reported to the MCA Steering group to identify opportunities for learning or areas which require additional support.
In addition, the planned processes for pre- and post-training assessment of learning will assess staff knowledge of the principles and processes.
What measures the Trust have in place to ensure that staff are aware of hospital passports and the contents of those and how they can seek advice and support if they do not understand or cannot locate a passport which should be available to them.
The current Health Passport was updated and agreed by a task and finish group of the Sheffield Adult Safeguarding Partnership, and agreed with Mencap, in 2019. The front page of the Health Passport prompts professionals to gain consent to treat or to act in the person’s best interests. In addition, the ‘All About Me’ booklet (developed by the Alzheimer’s Society) is available to support the identification of communication needs for dementia patients and this has been disseminated via the Dementia Steering Group.
Awareness of the Passport has been raised during the annual city-wide Safeguarding Awareness Weeks and Transition events. However, a recent audit by Sheffield Health and Social Care Trust showed that less than 50% of people on the case register had a Passport and they are now
5
working to increase this. In addition, a spot check in the hospital suggested that of those who did have a Passport, more than half had not brought it to hospital with them.
The Health Passport will be re-launched, along with the ‘All About Me’ and Hospital Communication Booklets as part of the MCA communication strategy. The communications will aim to raise awareness of the Passport and encourage staff to ask relevant patients if they have a Passport; if they do, staff should ensure that this is visible and accessible and if they do not, staff should advise the patient/carer to ask their provider to fill it in with them. As part of the re-launch staff will be advised to photocopy the Health Passport and give the original back to the patient (so it does not get mislaid), then ask the patient for permission to put the Passport in a visible place so that it is accessible to all staff who come into contact with the patient.
To support these communications, the Learning Disability Intranet Site will be updated to ensure clear visibility and accessibility of the Health Passport. In addition, the Transition Team will promote the use of the Health Passport when supporting young people to transition to adult services.
As part of the proposed programme of audits there will be a specific focus on learning disabilities, through a review of care of a sample of patients known to have a Learning Disability. This audit will include specific criteria to identify if the records reference a Health Passport or if the patient was asked if they had a Health Passport.
In addition to these specific actions, you also highlighted concerns about the fact that the verification of death form records Laura’s death as being expected, when this was not reflected in the views expressed by the staff caring for her. As requested, Dr , Clinical Lead for Infectious Diseases, has reviewed the verification of death process in this case and I attach a copy of his report for your information. Dr notes that, whilst at the start of Laura’s admission her death was not expected, this picture changed during her stay. On the last day of her life, Laura had a respiratory arrest from which she was successfully resuscitated, after which the decision was collectively made between the clinicians and Laura’s parents to move to best supportive care and not pursue further active treatment, escalation or resuscitation attempts. In this context, the death was expected and therefore Dr has concluded that the documentation was accurate.
Having outlined the actions we are taking in response to your report, I hope that I have been able to convey how seriously we have viewed this matter. We are absolutely committed to learning from Laura’s death and implementing these actions.
Finally, I hope that my response has addressed the concerns and actions you identified in your Report. Please contact me if you have any queries or points of clarification.
Prevention of Future Deaths Report – Laura Booth
I write to formally respond to your Prevention of Future Deaths (PFD) Report dated 5 May 2021, following the very sad death of Laura Booth. I wanted to say at the outset how saddened I am by Laura’s death and how sincerely sorry I am for the additional distress and upset the outstanding concerns you outline in your report have no doubt caused her parents. I truly hope that we can learn from this case and take actions to ensure as far as is possible that nothing similar happens again.
Firstly, I would like to thank you for acknowledging the progress we have made with regard to our nutrition services in response to this sad case.
I fully appreciate your concerns with regard to the knowledge and application of the requirements of the Mental Capacity Act (MCA) by the Trust’s clinicians, including; the understanding of best interest discussions; the need to engage the patient, family and carers in these discussions; and the need to fully document each and every time they occur. We acknowledge the lack of understanding by some of our staff with regard to the importance of Laura’s Health Passport, which, if it had been utilised correctly, would have ensured all staff understood her communication style, thereby supporting consistent involvement in decision-making.
Over the past few years the Trust has undertaken a wide range of actions to embed the requirements of the Mental Capacity Act (MCA) and ensure that there is proactive support for learning disability patients, and other patient groups who may lack full capacity. Prior to the Inquest into Laura’s death, we had started to give this area of work greater emphasis and the conclusions that you reached give further weight to the importance of this work, which includes: The development and delivery of training, which, as detailed later in this letter has now been strengthened to ensure all front-line clinical staff have the required knowledge. A range of resources for staff which are easily accessible via the Trust’s intranet site. These include clear and comprehensive guidance on the principles of the MCA, resources for raising staff awareness and contact details so that staff can access specialist support.
3
agreed to ensure the appropriate dissemination of information relating to MCA across relevant staff groups, in order to raise awareness.
In order to assess the impact of this training, the following measures have been put in place and are on-going: The current post-training evaluation will be replaced with a process of pre- and post- training assessment of learning to demonstrate increased knowledge. A programme of MCA/Best Interests audits commenced in June 2021, to examine the application of legislation in practice and to measure improvements post training. Clinical areas where poor compliance is identified will receive targeted training. Complaints will be analysed to identify any concerns relating to the application of MCA, which will be fed into the MCA steering group for action and into MCA staff training, where appropriate.
This training and the supporting resources will be further developed following the introduction of the Liberty Protection Safeguards in April 2022. The Trust has funded and is recruiting to a specialist team to support the implementation of this new process, which will further embed MCA processes and awareness across the organisation.
What action the Trust will take to ensure that senior clinicians are familiar with the provisions of the Mental Capacity Action and any subsequent legislation developed with the same aims and objectives and make this business as usual for those individuals and the junior doctors they supervise.
In addition to the mandatory training described above, additional training including workshops and master classes such as Assessing Mental Capacity are already available and bespoke training can be arranged, tailored to specific teams e.g. training on MCA/DoLS has recently been arranged with the senior clinical staff from Infectious Diseases, at their request.
We are committed to rolling out this more advanced training to all senior decision makers. This will initially be targeted at Clinical Directors who will then be tasked with deciding how best to deliver this within their directorates, which cover a wide variety of services. This approach will enable us to ensure training is tailored to the intended audience and that uptake is high. The progress of this advanced training will be monitored by the Mental Health Steering Group to ensure that all appropriate staff groups receive this training.
I also understand that you have kindly offered to deliver training and that you are meeting with Dr Deputy Medical Director to discuss the format of this training.
In addition, in order to ensure that we recruit staff with the appropriate skills and knowledge, questions relating to the understanding of the MCA and DoLS are being made available for use in interviews for senior clinicians.
How individuals who lack capacity will be supported to influence decisions about their own care as much as possible.
The need to ensure individuals who lack capacity are supported to influence decisions about their own care is explicit within the training described above, and is reflected in Trust documentation available for staff, including Best Interests Checklist and Best Interests Decision Record. These documents act as an aide memoire to guide staff through the best interests process and their use in practice is emphasised through the training process.
Resources to support patients with communication needs, such as the communication booklet, are available via the intranet and these, along with the Health Passport support staff to identify and respond to the communication needs of patients with a learning disability. In addition,
4
communication booklets have been given to each ward; further work is being undertaken to check that hard copies of the booklet are available in all areas and promote its use. The work to promote the use of the Health Passport is described in more detail later.
Reassuringly, in a recent survey of learning disability service users, run by the NHS Benchmarking Network, 84.2% of respondents felt staff explained things in a way they could understand (compared with 81.0% nationally) and 90.5% felt listened to (compared with 83.0% nationally).
How families are brought into these discussions where patients cannot make decisions for themselves and what measures are in/being brought into place to ensure that there is a clear audit trail of the thoughts and feelings of families and relatives.
The involvement of families is also reflected in the Best Interests Checklist and Best Interests Decision record, described above and there is clear guidance for staff about who must, where practicable, be included in consultation when deciding on best interests.
The importance of including family/advocates in decision making will continue to be made explicit in MCA training and the impact of this will be assessed, as described previously, through pre- and post-training evaluation of knowledge and audit of application in practice.
In the recent survey of learning disability service users, 94.4% of respondents felt staff listened to their family’s views (compared with 81.4% nationally).
What measures will be taken to ensure continuous compliance to both the practical application of the statutory regime as well as individual understanding of it.
As described previously, a programme of MCA/Best Interests audits commenced in June, to examine the application and recording of the MCA and Best Interests decision making process following the principles outlined in the MCA Code of Practice. The audit will include reviewing evidence of patient, family and/or advocate involvement and the use of the Health Passport. The results, which will be available in October 2021, will be used to identify clinical areas within the Trust requiring additional training and support.
Any breaches in lawful practice should be reported as an incident on Datix, by any member of staff. All such incidents are reviewed by the Specialist Advisor - MCA and DoL Safeguards and in future thematic analysis of these incidents will be reported to the MCA Steering group to identify opportunities for learning or areas which require additional support.
In addition, the planned processes for pre- and post-training assessment of learning will assess staff knowledge of the principles and processes.
What measures the Trust have in place to ensure that staff are aware of hospital passports and the contents of those and how they can seek advice and support if they do not understand or cannot locate a passport which should be available to them.
The current Health Passport was updated and agreed by a task and finish group of the Sheffield Adult Safeguarding Partnership, and agreed with Mencap, in 2019. The front page of the Health Passport prompts professionals to gain consent to treat or to act in the person’s best interests. In addition, the ‘All About Me’ booklet (developed by the Alzheimer’s Society) is available to support the identification of communication needs for dementia patients and this has been disseminated via the Dementia Steering Group.
Awareness of the Passport has been raised during the annual city-wide Safeguarding Awareness Weeks and Transition events. However, a recent audit by Sheffield Health and Social Care Trust showed that less than 50% of people on the case register had a Passport and they are now
5
working to increase this. In addition, a spot check in the hospital suggested that of those who did have a Passport, more than half had not brought it to hospital with them.
The Health Passport will be re-launched, along with the ‘All About Me’ and Hospital Communication Booklets as part of the MCA communication strategy. The communications will aim to raise awareness of the Passport and encourage staff to ask relevant patients if they have a Passport; if they do, staff should ensure that this is visible and accessible and if they do not, staff should advise the patient/carer to ask their provider to fill it in with them. As part of the re-launch staff will be advised to photocopy the Health Passport and give the original back to the patient (so it does not get mislaid), then ask the patient for permission to put the Passport in a visible place so that it is accessible to all staff who come into contact with the patient.
To support these communications, the Learning Disability Intranet Site will be updated to ensure clear visibility and accessibility of the Health Passport. In addition, the Transition Team will promote the use of the Health Passport when supporting young people to transition to adult services.
As part of the proposed programme of audits there will be a specific focus on learning disabilities, through a review of care of a sample of patients known to have a Learning Disability. This audit will include specific criteria to identify if the records reference a Health Passport or if the patient was asked if they had a Health Passport.
In addition to these specific actions, you also highlighted concerns about the fact that the verification of death form records Laura’s death as being expected, when this was not reflected in the views expressed by the staff caring for her. As requested, Dr , Clinical Lead for Infectious Diseases, has reviewed the verification of death process in this case and I attach a copy of his report for your information. Dr notes that, whilst at the start of Laura’s admission her death was not expected, this picture changed during her stay. On the last day of her life, Laura had a respiratory arrest from which she was successfully resuscitated, after which the decision was collectively made between the clinicians and Laura’s parents to move to best supportive care and not pursue further active treatment, escalation or resuscitation attempts. In this context, the death was expected and therefore Dr has concluded that the documentation was accurate.
Having outlined the actions we are taking in response to your report, I hope that I have been able to convey how seriously we have viewed this matter. We are absolutely committed to learning from Laura’s death and implementing these actions.
Finally, I hope that my response has addressed the concerns and actions you identified in your Report. Please contact me if you have any queries or points of clarification.
Sent To
- Sheffield Teaching Hospitals NHS Foundation Trust ›Sheffield Teaching Hospitals
Response Status
Linked responses
1 of 1
56-Day Deadline
4 Jul 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 14 February 2018 I commenced an investigation into the death of Laura Booth born on 14 December 1994. The investigation concluded at the end of the inquest on 26 April 2021. The conclusion of the inquest was:-
Laura Booth went into the Royal Hallamshire Hospital on 25 September 2016 for a routine procedure. She became unwell whilst she was a patient at the hospital and amongst other illnesses, she also developed malnutrition due to inadequate management of her nutritional needs. Her death was contributed to by neglect. She died at the Royal Hallamshire Hospital on 19 October 2016.
And I amended the medical cause of death to reflect:- 1a. Respiratory Failure 1b. Bronchopneumonia 1c. Partial Trisomy13 (Patau's Syndrome)
2. Malnutrition, Immunodeficiency (treated), Crohn's Disease (treated), Insulin-
dependent diabetes mellitus, juvenile arthritis (treated)
Laura Booth went into the Royal Hallamshire Hospital on 25 September 2016 for a routine procedure. She became unwell whilst she was a patient at the hospital and amongst other illnesses, she also developed malnutrition due to inadequate management of her nutritional needs. Her death was contributed to by neglect. She died at the Royal Hallamshire Hospital on 19 October 2016.
And I amended the medical cause of death to reflect:- 1a. Respiratory Failure 1b. Bronchopneumonia 1c. Partial Trisomy13 (Patau's Syndrome)
2. Malnutrition, Immunodeficiency (treated), Crohn's Disease (treated), Insulin-
dependent diabetes mellitus, juvenile arthritis (treated)
Circumstances of the Death
Laura Booth was required to go into hospital for a routine elective eye surgery because of in growing eyelashes. She had previously been under the care of Sheffield Children's Hospital however on becoming an adult she had transitioned to the care of Sheffield Teaching Hospitals which includes both the Royal Hallamshire Hospital and the Northern General Hospital. A plan was in place for Laura that should she need an inpatient admission, this would be facilitated, wherever possible, through ward E2 at the Royal Hallamshire Hospital.
This plan had been enacted successfully in April 2016 however following surgery on that occasion Laura's diabetes was not well managed by the hospital. This is acknowledged by the hospital and resulted in a decision being taken that when Laura was due to attend for her eye surgery in September 2016, she would be admitted the night before the surgery and be kept overnight to support her diabetes management. Her parents would be able to remain with her whenever she was an inpatient at the hospital.
When Laura attended at the hospital on 25 September 2016 it was clear that this message had not been adequately communicated and staff were not expecting her however the hospital was able to allocate Laura a room on the ophthalmology ward which was of sufficient size to accommodate Laura and her parents. It became clear, through the anaesthetic assessment, that Laura was not going to be able to have her operation when it became evident that she had issues with low potassium. This had been apparent on pre admission screening but had not been noted. As a result, Laura was kept in hospital to treat her low potassium and try to get her into a position where she was well enough for surgery.
It was clear that Laura required medical oversight rather than surgical oversight and from the point of her admission on 25 September 2016 to the point of her move to ward E2 on 29 September 2016 there were numerous attempts to move her care to a medical team. She did move on 29 September 2016 and was seen by a senior registrar from the gastroenterology team. On this occasion it was clear that there were concerns over Laura's nutrition and a request was made for her to be referred to the nutrition team.
A repeated request had to be made on 3 October 2016 and a referral was made.
This commenced a series of reviews by nutrition services and discussions with medical teams treating Laura although throughout Laura's admission there was no one individual identified to make decisions about Laura's nutrition and it is clear that Laura's nutritional needs were not managed or overseen by any individual. It was not until the 19 October 2016, which is the day that Laura died, that Dr took overall control of this decision and TPN determined to be appropriate for Laura.
From 29 September 2016 until 19 October 2016, although Laura's nutrition was a significant concern and was discussed by a number of professionals involved in her care there were no attempts to engage Laura or her parents in a best interests meeting to determine the way in which Laura's nutrition should be managed in her best interests. There appears to have been an incorrect view that Laura's father had indicated that NG feeding would not be tolerated by Laura however this was not the subject of an MDT meeting and subsequently not the subject of any best interests meeting; consequently, this option was unlawfully ruled out with decisions made in contravention of the requirements of the Mental Capacity Act 2005.
I made the following findings based on the evidence which I heard at the inquest:-
1. Laura's nutritional intake was a concern from her admission on 29 September 2016 on the basis of the Trust's own records. Despite this, feeding charts were not commenced.
2. Laura's nutritional intake was not given sufficient weight or discussion from 29 September 2016 to the 19 October 2016.
3. Clinical decisions were made for Laura unlawfully
4. There was an inappropriate weight placed on Laura's clinical history and myriad of diagnosis
5. Laura should have been discussed in an MDT and a formal plan and strategy should have been developed by no later than 7 October 2016 for nutrition
6. Alternative feeding, whether via NG tube or TPN should have been tried and commenced between 29 September 2016 and no later than 14 October 2016.
7. The decision not to adequately manager Laura's nutrition was a gross failure of her care.
8. Laura's malnutrition contributed to her death and contributed in a way which was more than minimal, negligible or trivial.
I have deliberately not focussed on Laura's underlying conditions in this summary of the circumstances of her death. As can be seen from the findings above, I believe that there was an inappropriate weight placed on these conditions and that resulted in her basic human needs being overlooked. For the sake of completeness, Laura was diagnosed with partial trisomy 13 (Patau's syndrome), immunodeficiency, Crohn's disease, juvenile arthritis and insulin dependent diabetes mellitus. It is significant that her immunodeficiency, Crohn's disease and arthritis were all controlled and inactive at the time of her admission on 25 September 2016 and her diabetes was well managed by Laura with support from her mum and dad.
This plan had been enacted successfully in April 2016 however following surgery on that occasion Laura's diabetes was not well managed by the hospital. This is acknowledged by the hospital and resulted in a decision being taken that when Laura was due to attend for her eye surgery in September 2016, she would be admitted the night before the surgery and be kept overnight to support her diabetes management. Her parents would be able to remain with her whenever she was an inpatient at the hospital.
When Laura attended at the hospital on 25 September 2016 it was clear that this message had not been adequately communicated and staff were not expecting her however the hospital was able to allocate Laura a room on the ophthalmology ward which was of sufficient size to accommodate Laura and her parents. It became clear, through the anaesthetic assessment, that Laura was not going to be able to have her operation when it became evident that she had issues with low potassium. This had been apparent on pre admission screening but had not been noted. As a result, Laura was kept in hospital to treat her low potassium and try to get her into a position where she was well enough for surgery.
It was clear that Laura required medical oversight rather than surgical oversight and from the point of her admission on 25 September 2016 to the point of her move to ward E2 on 29 September 2016 there were numerous attempts to move her care to a medical team. She did move on 29 September 2016 and was seen by a senior registrar from the gastroenterology team. On this occasion it was clear that there were concerns over Laura's nutrition and a request was made for her to be referred to the nutrition team.
A repeated request had to be made on 3 October 2016 and a referral was made.
This commenced a series of reviews by nutrition services and discussions with medical teams treating Laura although throughout Laura's admission there was no one individual identified to make decisions about Laura's nutrition and it is clear that Laura's nutritional needs were not managed or overseen by any individual. It was not until the 19 October 2016, which is the day that Laura died, that Dr took overall control of this decision and TPN determined to be appropriate for Laura.
From 29 September 2016 until 19 October 2016, although Laura's nutrition was a significant concern and was discussed by a number of professionals involved in her care there were no attempts to engage Laura or her parents in a best interests meeting to determine the way in which Laura's nutrition should be managed in her best interests. There appears to have been an incorrect view that Laura's father had indicated that NG feeding would not be tolerated by Laura however this was not the subject of an MDT meeting and subsequently not the subject of any best interests meeting; consequently, this option was unlawfully ruled out with decisions made in contravention of the requirements of the Mental Capacity Act 2005.
I made the following findings based on the evidence which I heard at the inquest:-
1. Laura's nutritional intake was a concern from her admission on 29 September 2016 on the basis of the Trust's own records. Despite this, feeding charts were not commenced.
2. Laura's nutritional intake was not given sufficient weight or discussion from 29 September 2016 to the 19 October 2016.
3. Clinical decisions were made for Laura unlawfully
4. There was an inappropriate weight placed on Laura's clinical history and myriad of diagnosis
5. Laura should have been discussed in an MDT and a formal plan and strategy should have been developed by no later than 7 October 2016 for nutrition
6. Alternative feeding, whether via NG tube or TPN should have been tried and commenced between 29 September 2016 and no later than 14 October 2016.
7. The decision not to adequately manager Laura's nutrition was a gross failure of her care.
8. Laura's malnutrition contributed to her death and contributed in a way which was more than minimal, negligible or trivial.
I have deliberately not focussed on Laura's underlying conditions in this summary of the circumstances of her death. As can be seen from the findings above, I believe that there was an inappropriate weight placed on these conditions and that resulted in her basic human needs being overlooked. For the sake of completeness, Laura was diagnosed with partial trisomy 13 (Patau's syndrome), immunodeficiency, Crohn's disease, juvenile arthritis and insulin dependent diabetes mellitus. It is significant that her immunodeficiency, Crohn's disease and arthritis were all controlled and inactive at the time of her admission on 25 September 2016 and her diabetes was well managed by Laura with support from her mum and dad.
Action Should Be Taken
I would ask that your responses specifically consider the following:-
1. What action the Trust shall carry out in order to address the failures and limitations in staff understanding so that the intended consequence of the Mental Capacity Act 2005 and the DOL Safeguarding provisions have meaningful practical effect on patients’ care.
2. What action the Trust will take to ensure that Senior clinicians are familiar with the provisions of the Mental Capacity Act and any subsequent legislation developed with the same aims and objectives and make this business as usual for those individuals and the junior clinicians they supervise.
3. How individuals who lack capacity will be supported to influence decisions about their own care as much as possible.
4. How families are brought into these discussions where patients cannot make decisions for themselves and what measures are in/being brought into place to ensure that there is a clear audit trail of the thoughts and feelings of families and relatives.
5. What measures will be taken to ensure continuous compliance to both the practical application of the statutory regime as well as individual understanding of it.
6. What measures the Trust have in place to ensure that staff are aware of hospital passports and the contents of those and how they can seek advice and support if they do not understand or cannot locate a passport which should be available to them.
1. What action the Trust shall carry out in order to address the failures and limitations in staff understanding so that the intended consequence of the Mental Capacity Act 2005 and the DOL Safeguarding provisions have meaningful practical effect on patients’ care.
2. What action the Trust will take to ensure that Senior clinicians are familiar with the provisions of the Mental Capacity Act and any subsequent legislation developed with the same aims and objectives and make this business as usual for those individuals and the junior clinicians they supervise.
3. How individuals who lack capacity will be supported to influence decisions about their own care as much as possible.
4. How families are brought into these discussions where patients cannot make decisions for themselves and what measures are in/being brought into place to ensure that there is a clear audit trail of the thoughts and feelings of families and relatives.
5. What measures will be taken to ensure continuous compliance to both the practical application of the statutory regime as well as individual understanding of it.
6. What measures the Trust have in place to ensure that staff are aware of hospital passports and the contents of those and how they can seek advice and support if they do not understand or cannot locate a passport which should be available to them.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.