Susan Sterland
PFD Report
All Responded
Ref: 2020-0062
All 1 response received
· Deadline: 26 Mar 2020
Coroner's Concerns (AI summary)
A deteriorating emergency department patient waited 40 hours without senior doctor review or available ward bed, potentially delaying critical diagnosis of an obstruction.
View full coroner's concerns
This was obviously a very busy time at the hospital. However, Ms Sterland was in the hospital for some 40 hours, she was not getting better, there were signs that she was deteriorating during the late morning and afternoon of 30 December, there was a plan to admit her to a ward but there were no beds available. My concern is that in this situation she was not seen by a senior doctor. If Ms Sterland had been seen by a senior doctor the evidence was that she would have had further investigation which would have led to earlier diagnosis of the obstruction and may have altered the outcome. The evidence at the inquest suggested that there are some categories of patients in the emergency department for whom a senior review is mandatory. It may be that the Trust would wish to consider whether the circumstances of this case suggest that there are other situations in which a senior review should be required.
Responses
Action Taken
Kettering General Hospital has updated its SOP for ED admissions (ED03) to clarify responsibilities, increased middle-grade shifts from 9 to 11 daily, and increased consultant presence with the aim of having two consultants in ED from 8:00 to 22:00. The EDU was decommissioned in March 2020, with plans to reinstate it post-COVID-19 with a new SOP addressing risks raised in the PFD report. (AI summary)
Kettering General Hospital has updated its SOP for ED admissions (ED03) to clarify responsibilities, increased middle-grade shifts from 9 to 11 daily, and increased consultant presence with the aim of having two consultants in ED from 8:00 to 22:00. The EDU was decommissioned in March 2020, with plans to reinstate it post-COVID-19 with a new SOP addressing risks raised in the PFD report. (AI summary)
View full response
Dear Sirs
Inquest concerning the death of Susan Sterland – PFD Response
Following the inquest of Susan Sterland that took place on the 23rd January 2020, Assistant Coroner considered his duty to issue a Prevention of Future Deaths Report (PFD) had been satisfied due to the evidence which he heard as part of the inquest.
The Coroner raised the following concern in relation to the Accident and Emergency Department – “my concern is that she was not seen by a senior doctor. If she had been seen by a senior doctor, the evidence was that she would have had further investigations which would have led to earlier diagnosis of the obstruction and may have altered the outcome. The evidence at the inquest suggested that there were some categories of patients in the emergency department for whom a senior review is mandatory. It may be that the Trust should wish to consider whether the circumstances of this case suggest that there are other situations in which a senior review should be required.”
Executive Offices
Rothwell Road
Kettering
Northants
NN16 8UZ
Main Switchboard: 01536 492000
Direct Dial:
Fax: 01536 493767
Web: www.kgh.nhs.uk
When calling, please ask for
2 As a result of the concerns which were raised by the Coroner, the Trust considered the measures which could be put in place to ensure that this concern would not be raised again in the future. The Trust confirmed to the Coroner that the four measures listed below were being considered and so the Trust has provided the following update on all of the four measures: :
1. A revision to the Standard Operating Practice to set out who is responsible for reviewing patients:
An updated Emergency Department (ED) Standard Operating Policy (SOP) ED01 was ratified on the 28th May 2020 in the Urgent Care Governance Meeting and a copy is enclosed with this letter. The SOP has been updated to reflect current practice to include the change of practice to Emergency Department (ED) admitting rights and reference to escalation and management as defined in the associated SOP ED03. The SOP now has a new expiry date of February 2022.
The updated SOP clearly reflects who is responsible for each patient within the ED.
The Department medical rota has been changed to increase the number of senior decision makers present within the department on each day. As a result the number of middle-grade shifts has been increased from 9 to 11 shifts, daily. In addition, the number of consultants in the department has been increased by adding a second consultant shift from 15:00 to 22.00 and we are aiming to have 2 consultants in ED from 08:00 to 22.00. This will allow a timely senior review of patients and will provide consultant ward rounds for EDU.
2. Review of the documentation for admittance to the EDU:
The EDU was decommissioned in March 2020 in response to Covid 19. The area where EDU was located is currently being used as ED Major cubicles which are part of the ED footprint.
When EDU is reinstated post COVID-19 it will have a different location and a new SOP will be created to reflect this and will take into account the specific risks raised within the PFD report. The SOP will clearly state which consultant will be responsible for daily ward rounds and patient ownership will be clearly stipulated. The EDU will not be re-commissioned until the new SOP is in place.
3
3. Confirmation of which consultant would be responsible for reviewing patients in the EDU:
Please refer to point 2.
4. Whether the EDU is being permanently removed:
Please refer to point 2.
As the Coroner will note the Trust has taken the necessary steps to address concerns raised. The Trust would like to offer assurance that the concerns have been actioned and appropriate measures put in place to avoid a similar incident happening again.
Inquest concerning the death of Susan Sterland – PFD Response
Following the inquest of Susan Sterland that took place on the 23rd January 2020, Assistant Coroner considered his duty to issue a Prevention of Future Deaths Report (PFD) had been satisfied due to the evidence which he heard as part of the inquest.
The Coroner raised the following concern in relation to the Accident and Emergency Department – “my concern is that she was not seen by a senior doctor. If she had been seen by a senior doctor, the evidence was that she would have had further investigations which would have led to earlier diagnosis of the obstruction and may have altered the outcome. The evidence at the inquest suggested that there were some categories of patients in the emergency department for whom a senior review is mandatory. It may be that the Trust should wish to consider whether the circumstances of this case suggest that there are other situations in which a senior review should be required.”
Executive Offices
Rothwell Road
Kettering
Northants
NN16 8UZ
Main Switchboard: 01536 492000
Direct Dial:
Fax: 01536 493767
Web: www.kgh.nhs.uk
When calling, please ask for
2 As a result of the concerns which were raised by the Coroner, the Trust considered the measures which could be put in place to ensure that this concern would not be raised again in the future. The Trust confirmed to the Coroner that the four measures listed below were being considered and so the Trust has provided the following update on all of the four measures: :
1. A revision to the Standard Operating Practice to set out who is responsible for reviewing patients:
An updated Emergency Department (ED) Standard Operating Policy (SOP) ED01 was ratified on the 28th May 2020 in the Urgent Care Governance Meeting and a copy is enclosed with this letter. The SOP has been updated to reflect current practice to include the change of practice to Emergency Department (ED) admitting rights and reference to escalation and management as defined in the associated SOP ED03. The SOP now has a new expiry date of February 2022.
The updated SOP clearly reflects who is responsible for each patient within the ED.
The Department medical rota has been changed to increase the number of senior decision makers present within the department on each day. As a result the number of middle-grade shifts has been increased from 9 to 11 shifts, daily. In addition, the number of consultants in the department has been increased by adding a second consultant shift from 15:00 to 22.00 and we are aiming to have 2 consultants in ED from 08:00 to 22.00. This will allow a timely senior review of patients and will provide consultant ward rounds for EDU.
2. Review of the documentation for admittance to the EDU:
The EDU was decommissioned in March 2020 in response to Covid 19. The area where EDU was located is currently being used as ED Major cubicles which are part of the ED footprint.
When EDU is reinstated post COVID-19 it will have a different location and a new SOP will be created to reflect this and will take into account the specific risks raised within the PFD report. The SOP will clearly state which consultant will be responsible for daily ward rounds and patient ownership will be clearly stipulated. The EDU will not be re-commissioned until the new SOP is in place.
3
3. Confirmation of which consultant would be responsible for reviewing patients in the EDU:
Please refer to point 2.
4. Whether the EDU is being permanently removed:
Please refer to point 2.
As the Coroner will note the Trust has taken the necessary steps to address concerns raised. The Trust would like to offer assurance that the concerns have been actioned and appropriate measures put in place to avoid a similar incident happening again.
Sent To
- Kettering General Hospital NHS Foundation Trust ›Kettering General Hospital
Response Status
Linked responses
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56-Day Deadline
26 Mar 2020
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 8 January 2019 I commenced an investigation into the death of Susan Sterland, age
76. The investigation concluded at the end of the inquest on 23 January 2020. The conclusion of the inquest was that Susan Sterland died of undiagnosed intestinal obstruction.
76. The investigation concluded at the end of the inquest on 23 January 2020. The conclusion of the inquest was that Susan Sterland died of undiagnosed intestinal obstruction.
Circumstances of the Death
Susan Sterland was brought by ambulance to the emergency department of Kettering General Hospital on 29th December 2018. She had intestinal obstruction which was not diagnosed.
Ms Sterland was diagnosed with constipation and admitted to the emergency decisions unit (EDU). The intention was to admit her to the medical ward but there were no available beds and so she remained on EDU for two nights. During the time she was in hospital she was seen by two experienced Advanced Care Practitioners (ACP) and by one junior doctor (FY1). She was never seen by senior doctor. During the day on 30 December she showed some signs of deterioration. Her condition then rapidly deteriorated during the late evening of 30 December 2018 but her care was not escalated. She collapsed and died early on 31 December 2018.
Ms Sterland was diagnosed with constipation and admitted to the emergency decisions unit (EDU). The intention was to admit her to the medical ward but there were no available beds and so she remained on EDU for two nights. During the time she was in hospital she was seen by two experienced Advanced Care Practitioners (ACP) and by one junior doctor (FY1). She was never seen by senior doctor. During the day on 30 December she showed some signs of deterioration. Her condition then rapidly deteriorated during the late evening of 30 December 2018 but her care was not escalated. She collapsed and died early on 31 December 2018.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.