Beryl Holland
PFD Report
All Responded
Ref: 2020-0037
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
All 2 responses received
· Deadline: 21 Apr 2020
Coroner's Concerns (AI summary)
Inconsistent hospital policies and a lack of national guidance for managing pressure ulcer risks in Emergency Departments led to prolonged waits and inadequate care for vulnerable patients.
View full coroner's concerns
_ The inquest heard that Holland was in the Emergency Department of the Acute Hospital for a significant period of time before ultimately been transferred to a ward. This was due to awaiting a suitable bed. She was vulnerable and at high risk of developing pressure ulcers. The trust in question had identified gaps in its processes and taken steps t0 reduce the risk of pressure ulcers developinglworsening in the Emergency Department: The inquest was told that there is no national guidance relating t0 the management oflreducing the risks of July Beryl pressure ulcers developing in an Emergency Department setting: As a result, Trusts will develop their own policies; which may not always recognise and react appropriately to the level of risk faced by those at risk of pressure ulcers particularly where there are prolonged periods of time in the Emergency Department:
Responses
Noted
NICE notes that its guideline CG179 provides relevant guidance on pressure sore prevention in emergency departments and no further action is required, but mentions a multi-year programme to improve how NICE produces and presents guidance and advice. (AI summary)
NICE notes that its guideline CG179 provides relevant guidance on pressure sore prevention in emergency departments and no further action is required, but mentions a multi-year programme to improve how NICE produces and presents guidance and advice. (AI summary)
View full response
Dear Ms Mutch; write in response to your correspondence, dated 25 February 2020, regarding the death of Beryl Holland: was very sorry t0 read of Ms Holland's death We have reflected on the circumstances surrounding Ms Holland's death, &nd the concerns raised in your report, relating (0 guidance on the managing and reducing the risks of pressure ulcers developing in an emergency department setting: The NICE guideline on the prevention and management of pressure sores (CG179) specifically provides advice t0 clinicians regarding patients receiving care in emergency department settings Recommendations 1.1.2 and 1.2.1 contain advice to clinicians on risk assessment for patients receiving care in emergency departments if they have a risk factor; such as: significantly limited mobility (for example, people with a spinal cord injury) significant loss of sensation previous or current pressure ulcer nutritional deficiency the inability to reposition themselves significant cognitive impairment: We therefore consider that NICE has produced relevant guidance and that no further action is required from us at this time in response to your report: We have initiated a multi-year programme of work called NICE Connect to review all elements of the way we produce and present our guidance and advice: The aim of this quality improvement project is to transform the way NICE produces and presents information to users, to ensure it can be found on our website more quickly and easily and is as clear and accessible as possible. We will be working and consulting with stakeholders throughout this long-term project. Further details of this work can be found on our website.
Action Taken
The Department for Health and Social Care notes the existence of NICE guidelines on pressure sore prevention and that Stockport NHS Foundation Trust has adopted a Patient Safety Checklist and improved access to dynamic mattresses. (AI summary)
The Department for Health and Social Care notes the existence of NICE guidelines on pressure sore prevention and that Stockport NHS Foundation Trust has adopted a Patient Safety Checklist and improved access to dynamic mattresses. (AI summary)
View full response
Dear Ms Mutch
Thank you for your letter of 25 February 2020 to Matt Hancock about the death of Beryl Holland. I am replying as Minister with responsibility for patient safety.
Please extend my sincere condolences to Ms Holland’s family and loved ones.
It is important that we look to make improvements where we can to ensure the highest standards of quality and safety in the NHS and I am grateful to you for bringing these matters to my attention.
I am aware that the National Institute for Health and Care Excellence (NICE) has advised you in its response that a clinical guideline is available on the Prevention and Management of Pressure Sores (CG1791) and that this guideline provides specific recommendations to clinicians in relation to patients receiving care in emergency department settings if they have a risk factor. It is the view of NICE that this guideline provides relevant guidance.
NHS trusts are expected to take into account NICE guidelines when developing Trust level policies. Risk assessment and care planning for the prevention of pressure ulcers should be undertaken in all relevant settings within a hospital and it is therefore expected that emergency departments will have local policies in place.
To assist NHS trusts, in 2017, NHS Improvement published an emergency department patient safety checklist2 that can be used to ensure skin assessments, appropriate care plans and follow up care are undertaken and recorded. The checklist is endorsed by NHS England, the Royal College of Emergency Medicine, and the Royal College of Nursing.
1 https://www.nice.org.uk/guidance/cg179
2 https://improvement.nhs.uk/resources/emergency-department-ed-patient-safety-checklist/
I am advised that the Stockport NHS Foundation Trust has adopted the Patient Safety Checklist for use in the emergency department at Stepping Hill Hospital, alongside other actions to improve processes around the identification and management of pressure ulcers. The emergency department works closely with the Tissue Viability Nurse Specialist and working together measures have been developed to improve patient safety and the quality of care. For example, through improved access to dynamic mattresses and the transfer of patients from a trolley to a bed if they are experiencing long waits and are identified to be at risk.
I hope this response is helpful.
NADINE DORRIES
Thank you for your letter of 25 February 2020 to Matt Hancock about the death of Beryl Holland. I am replying as Minister with responsibility for patient safety.
Please extend my sincere condolences to Ms Holland’s family and loved ones.
It is important that we look to make improvements where we can to ensure the highest standards of quality and safety in the NHS and I am grateful to you for bringing these matters to my attention.
I am aware that the National Institute for Health and Care Excellence (NICE) has advised you in its response that a clinical guideline is available on the Prevention and Management of Pressure Sores (CG1791) and that this guideline provides specific recommendations to clinicians in relation to patients receiving care in emergency department settings if they have a risk factor. It is the view of NICE that this guideline provides relevant guidance.
NHS trusts are expected to take into account NICE guidelines when developing Trust level policies. Risk assessment and care planning for the prevention of pressure ulcers should be undertaken in all relevant settings within a hospital and it is therefore expected that emergency departments will have local policies in place.
To assist NHS trusts, in 2017, NHS Improvement published an emergency department patient safety checklist2 that can be used to ensure skin assessments, appropriate care plans and follow up care are undertaken and recorded. The checklist is endorsed by NHS England, the Royal College of Emergency Medicine, and the Royal College of Nursing.
1 https://www.nice.org.uk/guidance/cg179
2 https://improvement.nhs.uk/resources/emergency-department-ed-patient-safety-checklist/
I am advised that the Stockport NHS Foundation Trust has adopted the Patient Safety Checklist for use in the emergency department at Stepping Hill Hospital, alongside other actions to improve processes around the identification and management of pressure ulcers. The emergency department works closely with the Tissue Viability Nurse Specialist and working together measures have been developed to improve patient safety and the quality of care. For example, through improved access to dynamic mattresses and the transfer of patients from a trolley to a bed if they are experiencing long waits and are identified to be at risk.
I hope this response is helpful.
NADINE DORRIES
Sent To
- National Institute for Health and Care Excellence
Response Status
Linked responses
2 of 1
56-Day Deadline
21 Apr 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 10h July 2019, | commenced an investigation into the death of Beryl Holland. The investigation concluded on the gth January 2020 and the conclusion was one of Accidental Death: The medical cause of death was 1a) Hospital acquired pneumonia; 1b) Neck of femur fracture; Ic) Fall; Il) Myocardial infarction; type 1 diabetes, pressure ulcers, dementia. CIRCUMSTANCES OF THE DEATH Beryl Holland sustained a fractured neck of femur at the care home where she resided after a fall. She had poor skin integrity and was high risk in relation to pressure ulcers: She was admitted, via the Emergency Department, to Stepping Hill Hospital and operated on. Post operatively she continued to decline. She died at Stepping Hill Hospital on 7th 2019. CQRONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken: In the circumstances it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows_ The inquest heard that Holland was in the Emergency Department of the Acute Hospital for a significant period of time before ultimately been transferred to a ward. This was due to awaiting a suitable bed. She was vulnerable and at high risk of developing pressure ulcers. The trust in question had identified gaps in its processes and taken steps t0 reduce the risk of pressure ulcers developinglworsening in the Emergency Department: The inquest was told that there is no national guidance relating t0 the management oflreducing the risks of July Beryl pressure ulcers developing in an Emergency Department setting: As a result, Trusts will develop their own policies; which may not always recognise and react appropriately to the level of risk faced by those at risk of pressure ulcers particularly where there are prolonged periods of time in the Emergency Department: ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power t0 take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by 21st April 2020. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely daughter of the deceased; 2) Care Quality Commission, who may find it useful or 0f interest am also under a to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner_ Alison Mutch OBE HM Senior Coroner 25.02.2020 days duty
Circumstances of the Death
Beryl Holland sustained a fractured neck of femur at the care home where she resided after a fall. She had poor skin integrity and was high risk in relation to pressure ulcers: She was admitted, via the Emergency Department, to Stepping Hill Hospital and operated on. Post operatively she continued to decline. She died at Stepping Hill Hospital on 7th
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power t0 take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.