Blaithin Buckley
PFD Report
All Responded
Ref: 2019-0465
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
All 1 response received
· Deadline: 16 Nov 2019
Coroner's Concerns (AI summary)
An unexplained delay occurred in calling an ambulance to transfer a patient from a mental health setting during a medical emergency, with unclear policies regarding ambulance activation.
View full coroner's concerns
In the circumstances it is my statutory to report to you. The in calling for an ambulance to transfer Ms Buckley to the General Hospital in a clear medical emergency_ There was no evidence before inquest to explain the delay between 23.20 and 23.44. Whilst it had been accepted that senior clinicians, with greater medical knowledge that the paramedics, formed the medical emergency team, St Andrews as a mental health setting was required to transfer Ms Buckley to A&E in event. It was unclear whether the policieslprocedures requiring the mobilisation of the medical emergency team included guidance on whether an ambulance should be called, and when:
Responses
Action Taken
St Andrews Healthcare sent a red-top alert concerning the NEWS chart, refreshed NEWS training, is reviewing the deteriorating patient policy, has implemented a change so an ambulance is called when a medical emergency is called, and responses to medical emergencies will be monitored at governance meetings. (AI summary)
St Andrews Healthcare sent a red-top alert concerning the NEWS chart, refreshed NEWS training, is reviewing the deteriorating patient policy, has implemented a change so an ambulance is called when a medical emergency is called, and responses to medical emergencies will be monitored at governance meetings. (AI summary)
View full response
Dear Ms Devonish Ref: Blaithin Grianne Buckley deceased Further to the Regulation 28 notice received by St Andrew's Healthcare dated 15 September 2018, I am providing a response to the matter of concern which was the delay in calling for an ambulance to transfer Ms Buckley to the General Hospital. While the evidence provided to the Court indicated that an earlier arrival at the General Hospital would not have altered the outcome in this instance, St Andrew's recognises that there is a need for greater clarity around the recognition of a medical emergency and how and when an ambulance is called. To that end the Charity has taken the following steps:
1) The Charity uses the National Early Warning System (NEWS) recording system to aid the recognition of the deteriorating patient. A 'red -top alert' - ie a Charity wide alerting notice - has been sent out concerning the use of the National Early Warning System (NEWS) chart. This alert has been further discussed at governance meetings at different levels to increase awareness and to confirm the ongoing and correct use of the chart. -Action completed on 10 September 2019.
2) NEWS training is mandatory for all staff as an e-learning module and the training has been refreshed and continues to be rolled out as part of the Immediate Life Support training for all registered nursing staff.
3) The policy concerning the management of a deteriorating patient is being reviewed and refreshed to provide clarity on the actions to be taken in the event of a patient experiencing deteriorating physical health and requiring medical intervention. This is due for implementation on or before 1 January 2020.
4) One specific and significant change in the procedure that has already been implemented is that when a medical emergency is called, an ambulance is also called rather than leaving it to the discretion of the nursing team as was previously the case. This will enable a faster response to medical emergencies. Action completed on 7 November 2019
5) Responses to medical emergencies including ambulance attendances will be monitored in the relevant governance meeting chaired by the Director of Physical Healthcare (the monthly physical healthcare group) with necessary escalation where problems or challenges are found.
6) These changes have been shared with NHSE specialist commissioning (the lead commissioner for St Andrew's) and will continue to be monitored in the regular bi-monthly NHSE St Andrew's Quality meetings. [ ~\ INVESTORS ~JIN PEOPLE Registered Office St Andrew's Healthcare, B,lling Road, Northampton NNl SDG Telephone 01604 616000 Website www srah.org Registered Charity Number 1104951 Old Charity Number 202659 Company Number 5176998
EALTHCA~E Executive Directorate
Please do contact me if you require any further clarification or information about this matter and the actions we are taking to address this issue.
1) The Charity uses the National Early Warning System (NEWS) recording system to aid the recognition of the deteriorating patient. A 'red -top alert' - ie a Charity wide alerting notice - has been sent out concerning the use of the National Early Warning System (NEWS) chart. This alert has been further discussed at governance meetings at different levels to increase awareness and to confirm the ongoing and correct use of the chart. -Action completed on 10 September 2019.
2) NEWS training is mandatory for all staff as an e-learning module and the training has been refreshed and continues to be rolled out as part of the Immediate Life Support training for all registered nursing staff.
3) The policy concerning the management of a deteriorating patient is being reviewed and refreshed to provide clarity on the actions to be taken in the event of a patient experiencing deteriorating physical health and requiring medical intervention. This is due for implementation on or before 1 January 2020.
4) One specific and significant change in the procedure that has already been implemented is that when a medical emergency is called, an ambulance is also called rather than leaving it to the discretion of the nursing team as was previously the case. This will enable a faster response to medical emergencies. Action completed on 7 November 2019
5) Responses to medical emergencies including ambulance attendances will be monitored in the relevant governance meeting chaired by the Director of Physical Healthcare (the monthly physical healthcare group) with necessary escalation where problems or challenges are found.
6) These changes have been shared with NHSE specialist commissioning (the lead commissioner for St Andrew's) and will continue to be monitored in the regular bi-monthly NHSE St Andrew's Quality meetings. [ ~\ INVESTORS ~JIN PEOPLE Registered Office St Andrew's Healthcare, B,lling Road, Northampton NNl SDG Telephone 01604 616000 Website www srah.org Registered Charity Number 1104951 Old Charity Number 202659 Company Number 5176998
EALTHCA~E Executive Directorate
Please do contact me if you require any further clarification or information about this matter and the actions we are taking to address this issue.
Sent To
- General Council
Response Status
Linked responses
1 of 1
56-Day Deadline
16 Nov 2019
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 11 September 2019 commenced an investigation into the death of Blaithin Grianne Buckley, aged 26. The investigation concluded at the end of the inquest on 13 September 2019. The conclusion of the inquest was that her death was a Misadventure and that the medical cause of death was: 1a. Hypoxic brain injury 1b. Out of hospital cardiac arrest 1c. Hanging Emotionally Unstable Personality Disorder jury found that the death had been contributed to by a breach of procedure at St Andrews in to lock the phone booth; an inadequate level of patient history transferred from Wootton Lawn to St Andrews (in particular the previous history of ligature by phone cord); an insufficient process for calling the ambulance service following the incident
Circumstances of the Death
Ms Buckley died on 30 April 2018 at Northampton General Hospital following being found hanging in a phone booth on the Bayley Ward at St Andrews Healthcare on 26 April 2018 at 23.20, whilst on 5 minute observations Contrary to the Trust policy, the phone booth door had been left unlocked_ The Trust medical emergency team was alerted to the incident through ascom at 23.23 CPR and life support commenced to good effect Upon being found Ms Buckley had been conscious_ 'She then fell unconscious with fixed and dilated pupils. The experienced medical emergency team returned a pulse and rapid heart beat whilst awaiting arrival of an ambulance. The first ambulance arrived at 00.02,having been called at 23.44 Ms Buckley was transferred to Northampton General Hospital at 00.42 in a comatose condition; Brain stem testing on 30 April 2018 recognised that Iife was extinct: The failing
The critical care consultant at Northampton General Hospital gave evidence that he suspected that an earlier arrival at hospital would not have altered the outcome as 5 minutes was sufficient to establish permanent brain damage
The critical care consultant at Northampton General Hospital gave evidence that he suspected that an earlier arrival at hospital would not have altered the outcome as 5 minutes was sufficient to establish permanent brain damage
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you or your organisation have the power to take such action;
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.