Maureen Brown
PFD Report
Partially Responded
Ref: 2020-0021
Coroner's Concerns (AI summary)
The electronic patient transfer system provides insufficient information for effective handovers between wards, as national policy limits the data shared, risking missed critical details.
View full coroner's concerns
1. Evidence emerged during the inquest that the electronic transfer information is the only information that the receiving ward is given before a patient is transferred. Other relevant information, that is necessary for an effective handover to take place, can be missed as the electronic transfer system limits how much information can be recorded.
2. Evidence was heard regarding the steps that the Royal Derby Hospital has made to remedy this issue. However, the national policy still states that the only piece of information necessary for a transfer is the electronic transfer information.
2. Evidence was heard regarding the steps that the Royal Derby Hospital has made to remedy this issue. However, the national policy still states that the only piece of information necessary for a transfer is the electronic transfer information.
Responses
Noted
NHS England states that there is a national Minimum Dataset for transfers of patients between hospitals, overseen by NHS Digital. Where inter-hospital transfers occur, it is incumbent on the Trust or provider to ensure they have robust handover and transfer of information procedures. (AI summary)
NHS England states that there is a national Minimum Dataset for transfers of patients between hospitals, overseen by NHS Digital. Where inter-hospital transfers occur, it is incumbent on the Trust or provider to ensure they have robust handover and transfer of information procedures. (AI summary)
View full response
Dear Miss Serrano,
Re: Regulation 28 Report following the Inquest touching upon the death of Maureen Brown
Thank you for your Prevention of Future Deaths Report (the “report”) dated 4th February 2019 concerning the death of Maureen Brown. I am sorry for the significant delay in our response. Please share my deep condolences with Mrs Brown’s family.
The regulation 28 report concludes Mrs Brown’s death was a result of
1a Subdural haemorrhage due to; 1b Fall
Following the inquest you raised concerns in your Regulation 28 Report to NHS England relating to the Trust and national handover processes. I understand that the Trust has responded to address the specific learning with regard their own internal patient transfer processes.
In your report you express concern that “the national policy still states the only piece of information necessary for a transfer is the electronic transfer information”. I am assured by my colleagues at NHSX that there is a national Minimum Dataset (MDS) for transfers of patients between hospitals; Inter-Provider Transfer Administrative Minimum Data Set. This is overseen by NHS Digital. This does not relate to transfers of patients between wards within a single healthcare provider (a Trust in this case) and in such circumstances Trusts would be expected to have their own policies and protocols to govern the minimum data provided between departments to facilitate an effective transfer of patient information, following relevant clinical standards. On that basis, the actions taken by University Hospitals Of Derby And Burton NHS Foundation Trust would be relevant to your concerns.
National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH
8th February 2021
There is no national policy for a Minimum Dataset for inter-hospital transfers, as was the case in Mrs Brown’s care, and where these occur it would be incumbent on the Trust or provider to ensure they have robust handover and transfer of information procedures. My Regional Colleagues have had assurance from the Trust of the changes they have made and the response to learning that has been implemented.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report following the Inquest touching upon the death of Maureen Brown
Thank you for your Prevention of Future Deaths Report (the “report”) dated 4th February 2019 concerning the death of Maureen Brown. I am sorry for the significant delay in our response. Please share my deep condolences with Mrs Brown’s family.
The regulation 28 report concludes Mrs Brown’s death was a result of
1a Subdural haemorrhage due to; 1b Fall
Following the inquest you raised concerns in your Regulation 28 Report to NHS England relating to the Trust and national handover processes. I understand that the Trust has responded to address the specific learning with regard their own internal patient transfer processes.
In your report you express concern that “the national policy still states the only piece of information necessary for a transfer is the electronic transfer information”. I am assured by my colleagues at NHSX that there is a national Minimum Dataset (MDS) for transfers of patients between hospitals; Inter-Provider Transfer Administrative Minimum Data Set. This is overseen by NHS Digital. This does not relate to transfers of patients between wards within a single healthcare provider (a Trust in this case) and in such circumstances Trusts would be expected to have their own policies and protocols to govern the minimum data provided between departments to facilitate an effective transfer of patient information, following relevant clinical standards. On that basis, the actions taken by University Hospitals Of Derby And Burton NHS Foundation Trust would be relevant to your concerns.
National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH
8th February 2021
There is no national policy for a Minimum Dataset for inter-hospital transfers, as was the case in Mrs Brown’s care, and where these occur it would be incumbent on the Trust or provider to ensure they have robust handover and transfer of information procedures. My Regional Colleagues have had assurance from the Trust of the changes they have made and the response to learning that has been implemented.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Sent To
- NHS England
- University Hospital of Derby and Burton
Response Status
Linked responses
1 of 2
56-Day Deadline
24 Mar 2020
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 the 12th November 2019, I commenced an investigation into the death of Mrs Maureen Ann Brown. The investigation concluded at the end of the inquest on the 3 February 2020. The conclusion of the inquest was a short narrative conclusion stating:
“On the 1 June 2019 at the Coach House, Derby Road, Milford, Belper, Derbyshire, from a subdural haemorrhage caused by a fall whilst a patient at the Royal Derby Hospital. On being transferred from MAU to ward 405 information relevant to her falls risk assessment was known, but not recorded within the electronic transfer information. As a consequence ward 405 were not made aware of information which would have led the deceased having an increased supervision care bundle”.
The cause of death was:
1a Subdural haemorrhage due to; 1b Fall.
“On the 1 June 2019 at the Coach House, Derby Road, Milford, Belper, Derbyshire, from a subdural haemorrhage caused by a fall whilst a patient at the Royal Derby Hospital. On being transferred from MAU to ward 405 information relevant to her falls risk assessment was known, but not recorded within the electronic transfer information. As a consequence ward 405 were not made aware of information which would have led the deceased having an increased supervision care bundle”.
The cause of death was:
1a Subdural haemorrhage due to; 1b Fall.
Circumstances of the Death
i) Mrs Brown was admitted to the Royal derby Hospital on the 16th April 2019. This was following a referral from her GP. This was for a urine sample showing pseudomonas, and the need for intravenous antibiotics. She was admitted under the Medical Assessment Unit (“MAU”) and transferred to ward 405. ii) Before her transfer, Mrs Browns’ daughter made the staff on MAU aware that Mrs Brown was increasingly confused due to the infection and may try and get out of her bed and as such was at an increased risk of falls. In addition, she disclosed that Mrs Brown had had a previous fall whilst she was a patient at the Royal Derby Hospital. iii) When a patient is ready for transfer an electronic handover is completed by the transferring ward. This is the only information that the receiving ward have access to at the point of accepting a patient to their ward. The
[IL1: PROTECT] information given by the Mrs Browns’ daughter, was not recorded in the electronic handover. iv) On being admitted to Ward 405 a Falls Risk Assessment was carried out, based on the information received from MAU. She was deemed to be a high risk of falls and falls preventions measures were put in place. These included bed rails and a call buzzer. She was placed onto a normal ward. However, had the information supplied by Mrs Browns’ daughter been included on the electronic transfer information, Mrs Brown would have been assessed as a high Risk of falls as well as needing an Increased Supervision Care Bundle. v) An Increased Supervision Care Bundle would have meant that Mrs Brown would have been put onto a ward with only 3 other patients, rather than a full hospital ward, and there would have been constant supervision by a nurse. vi) She subsequently fell from her bed. This caused her to suffer a bleed to the brain from which, she did not recover. vii) It was accepted by the Royal Derby Hospital that had Mrs Brown been on the Increased Supervision Care Bundle, it was more likely than it was not that she would not have fallen.
[IL1: PROTECT] information given by the Mrs Browns’ daughter, was not recorded in the electronic handover. iv) On being admitted to Ward 405 a Falls Risk Assessment was carried out, based on the information received from MAU. She was deemed to be a high risk of falls and falls preventions measures were put in place. These included bed rails and a call buzzer. She was placed onto a normal ward. However, had the information supplied by Mrs Browns’ daughter been included on the electronic transfer information, Mrs Brown would have been assessed as a high Risk of falls as well as needing an Increased Supervision Care Bundle. v) An Increased Supervision Care Bundle would have meant that Mrs Brown would have been put onto a ward with only 3 other patients, rather than a full hospital ward, and there would have been constant supervision by a nurse. vi) She subsequently fell from her bed. This caused her to suffer a bleed to the brain from which, she did not recover. vii) It was accepted by the Royal Derby Hospital that had Mrs Brown been on the Increased Supervision Care Bundle, it was more likely than it was not that she would not have fallen.
Action Should Be Taken
1. You may wish to consider the NHS policy and procedures for patient transfer.
Copies Sent To
of the deceased
Miss Emma Serrano Assistant Coroner Derby and Derbyshire Coroners Area
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.