Patricia Palin
PFD Report
Partially Responded
Ref: 2018-0183
Coroner's Concerns (AI summary)
Healthcare providers lacked access to GP records, A&E was understaffed, essential medication administration was delayed, and red flag signs of sepsis were missed due to inadequate examination and protocol adherence.
View full coroner's concerns
In the circumstances it is my statutory to report to you. Shropdoc personnel, be that Doctors or Urgent Care Practitioners are not able to access the referring patients GP records This meant that they did not have the full picture of Patricia'$ past medical history before administering any advice or treatment: This is not a one off isolated incident and applies to every case that is referred to Shropdoc_ Evidence was given at the inquest the Shropdoc Urgent Care Practitioners that it would have assisted them. During the evening of the 1st October 2017, there were only two A&E Doctors on a third had telephoned in sick ): Too few Doctors were therefore on in general to cover patient needs and there did not seem to be in place a programme for trying to get a third Doctor to replace the Doctor who had telephoned in sick: heard evidence that a prescribed drug Ertapenem was not in stock within the A&E department and that led to a delay of some two hours and twenty five minutes until administration. Other suitable alternative were available but not considered. Whilst there was a general awareness of the dangers of sepsis from the Shropdoc and Hospital witness evidence; Red signs of sepsis were missed. bandages were not removed to allow full top to toe examination: Sepsis six care bundles were not followed in accordance with guidelines_ duty from duty duty drugs flag - Leg
AcTIOn SKOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
AcTIOn SKOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
Responses
Action Planned
The Trust describes a process for backfilling vacant shifts in the Emergency Department. Also, the Trust will write to practices encouraging GPs to discuss the benefits of allowing an enhanced SCR with all their patients with chronic illness. (AI summary)
The Trust describes a process for backfilling vacant shifts in the Emergency Department. Also, the Trust will write to practices encouraging GPs to discuss the benefits of allowing an enhanced SCR with all their patients with chronic illness. (AI summary)
View full response
Dear Mr Westerman Re: Regulation 28 Patricia Palin deceased Further to my letter of 21 August 2018, would like to once again offer my sincere apologies for the delay in responding to your Regulation 28 report note that the first point related to another organisation and SO will address each of the points you have set out in turn, which relate to Shrewsbury and Telford Hospitals NHS Trust Too few Doctors were on duty in general to cover patient needs and there did not seem to be programme in place for trying to third Doctor to replace the Doctor who phoned in sick The Trust does have process in place for trying to backfill vacant shifts in the Emergency Department. At the first instance we will attempt to contact our own doctors via the Departmental Consultants or Medical Staffing representative making contact We will also advertise via external agencies at the same time to ensure that every attempt is made to fill the gap: attach a copy of the flow charts used to backfill vacant shifts_ However, on occasion if the sickness is short notice, as with any organisation, it is less simple to get cover. However; we do everything in our power to ensure the shift is covered. Due to the fragility of the workforce both in the locality and nationally , we usually already have numerous requests out to agency, as as our own staff picking up additional shifts, therefore it is not always possible to cover when staff call in at the last minute to cancel their shifts Ertapenem was not in stock and led to some hours 25 minutes delay in administration. Other suitable drugs were in stock; but not considered_ The Doctor prescribing the Ertapenem was not made aware that it was not available in the department; SO was unable to consider an alternativve The outcomes of the Root Cause Investigation were discussed with the team for learning to ensure communication is improved in the future. Furthermore, the drug is now stocked in the Emergency Department; to avoid recurrence in the future_ Whilst there was general awareness of the dangers from sepsis from the Hospital witness evidence: a) Red flags of sepsis were missed b) Leg bandages were not removed to allow for a full top to toe examination c) Sepsis 6 care bundles were not followed in accordance with guidelines Proud To Care Make It Happen We Value Respect Together We Achieve get well
The Root Cause Analysis was shared with the staff involved in order for_lessons to be learnt by the individuals involved in Mrs Palin's care. This was reflected byDr Roylwho attested to this in the Inquest hearing: In addition to this the Trust has carried out work on Sepsis and much more is planned through the Trust: In the last few years our organisation partnered with Virginia Mason Hospital in America, in order to improve patient safety and care As part of this, one of the Value Streams has focused on Sepsis and improving care for patients with this condition. Some of the improvements which are rolled out include: Revised Sepsis Screening Tool a revised version was created by Surgical Assessment Unit (SAU) staff, which increased compliance to 100% in that area Sepsis Trolley the SAU team introduced a bespoke sepsis trolley to store all of the items required to provide timely treatment for patients who are diagnosed with sepsis generating greater efficiency and reliability based on 'set up reduction' Sepsis Box the box placed all the items required in one place in order that a diagnosis can be obtained quickly (Ward 28). The Critical Care Outreach Team have also developed new Sepsis Web page on the Trust Intranet with information and links_ On this the team will be doing 'Spotlight' of the month to highlight good practice from various wards around the hospital to raise awareness of sepsis, this should keep sepsis awareness fresh and in the minds of everyone. However; given that Mrs Palin's delays were based in the Emergency Department wish to you update you on the work which has taken place and the on-going plans to improve sepsis care in ED specifically. Our Critical Care Outreach Team commenced a programme of sepsis education in both Emergency Departments , as of last week; to date 20 staff have been trained. The education is targeting all clinical staff in the department; however this is limited to availability of staff due to work load: The training sessions are taking place daily, days week The feedback has been really positive from all staff. The areas covered within the teaching session are recognition using visual signs, as well as recognition using the Sepsis screening tool. The Team then look at the Sepsis Six pathway in detail and discuss the importance of delivering this within the one hour time frame. Finally reference cards are provided to staff to keep highlighting the sepsis six pathway and signslsymptoms. Alongside this we are reviewing the trolleys in the department; with the possibility of trialling trolley that will allow for us to put everything into the trolley for immediate care of the septic patient; this includes antibiotics and fluids. The existing trolley in place does not carry everything required for immediate care. We are also developing a Patient Group Directive which will allow Senior Band 5 Nurses and Band 6 Nurses to deliver the fluids and antibiotics within the one hour required time frame in the event that a Doctor is not available to meet the demands of the one hour time frame: This is a huge step for us and one that has been welcomed by all the nursing staff within the ED_ Both ED's have Practice Education nurses who will continue to ensure all staff are up to date with their sepsis training: Sepsis Champions have also been chosen to be a Iink within the ED, and they will work closely with the Critical Care Outreach Team to continue the education and provide support for all staff within the ED: The Team are also in the process of . working with the Medical Teams to ensure that all the Doctors are trained in Sepsis recognition and treatment; Critical Care Outreach will continue to support the education and training in these areas for as long is required. Proud To Care Make It Happen We Value Respect Together We Achieve being New
hope that have been able to assure you that whilst we recognise that Mrs Palin's care was not at the standard we aspire to provide to our patients, we are taking all the necessary steps to improve the care we provide to our patients in the future. This is not something which we can do overnight and will take some time and constant review, to ensure that the improvements we are making, are successful: Please do contact me if you have any further questions at this time
The Root Cause Analysis was shared with the staff involved in order for_lessons to be learnt by the individuals involved in Mrs Palin's care. This was reflected byDr Roylwho attested to this in the Inquest hearing: In addition to this the Trust has carried out work on Sepsis and much more is planned through the Trust: In the last few years our organisation partnered with Virginia Mason Hospital in America, in order to improve patient safety and care As part of this, one of the Value Streams has focused on Sepsis and improving care for patients with this condition. Some of the improvements which are rolled out include: Revised Sepsis Screening Tool a revised version was created by Surgical Assessment Unit (SAU) staff, which increased compliance to 100% in that area Sepsis Trolley the SAU team introduced a bespoke sepsis trolley to store all of the items required to provide timely treatment for patients who are diagnosed with sepsis generating greater efficiency and reliability based on 'set up reduction' Sepsis Box the box placed all the items required in one place in order that a diagnosis can be obtained quickly (Ward 28). The Critical Care Outreach Team have also developed new Sepsis Web page on the Trust Intranet with information and links_ On this the team will be doing 'Spotlight' of the month to highlight good practice from various wards around the hospital to raise awareness of sepsis, this should keep sepsis awareness fresh and in the minds of everyone. However; given that Mrs Palin's delays were based in the Emergency Department wish to you update you on the work which has taken place and the on-going plans to improve sepsis care in ED specifically. Our Critical Care Outreach Team commenced a programme of sepsis education in both Emergency Departments , as of last week; to date 20 staff have been trained. The education is targeting all clinical staff in the department; however this is limited to availability of staff due to work load: The training sessions are taking place daily, days week The feedback has been really positive from all staff. The areas covered within the teaching session are recognition using visual signs, as well as recognition using the Sepsis screening tool. The Team then look at the Sepsis Six pathway in detail and discuss the importance of delivering this within the one hour time frame. Finally reference cards are provided to staff to keep highlighting the sepsis six pathway and signslsymptoms. Alongside this we are reviewing the trolleys in the department; with the possibility of trialling trolley that will allow for us to put everything into the trolley for immediate care of the septic patient; this includes antibiotics and fluids. The existing trolley in place does not carry everything required for immediate care. We are also developing a Patient Group Directive which will allow Senior Band 5 Nurses and Band 6 Nurses to deliver the fluids and antibiotics within the one hour required time frame in the event that a Doctor is not available to meet the demands of the one hour time frame: This is a huge step for us and one that has been welcomed by all the nursing staff within the ED_ Both ED's have Practice Education nurses who will continue to ensure all staff are up to date with their sepsis training: Sepsis Champions have also been chosen to be a Iink within the ED, and they will work closely with the Critical Care Outreach Team to continue the education and provide support for all staff within the ED: The Team are also in the process of . working with the Medical Teams to ensure that all the Doctors are trained in Sepsis recognition and treatment; Critical Care Outreach will continue to support the education and training in these areas for as long is required. Proud To Care Make It Happen We Value Respect Together We Achieve being New
hope that have been able to assure you that whilst we recognise that Mrs Palin's care was not at the standard we aspire to provide to our patients, we are taking all the necessary steps to improve the care we provide to our patients in the future. This is not something which we can do overnight and will take some time and constant review, to ensure that the improvements we are making, are successful: Please do contact me if you have any further questions at this time
Sent To
- Shrewsbury and Telford Hospital NHS Trust
Response Status
Linked responses
1 of 2
56-Day Deadline
2 Sep 2018
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 4th October 2017 commenced an investigation into the death of Patricia Violet PALIN, dob 3rd November 1936. The investigation concluded at the end of the inquest on 6th June 2018 and the conclusion was one of Natural Causes. The medical cause of death was la. Sepsis 1b. Cellulitis Right Leg 2. Liver Cirrhosis, Hypertension, Ischaemic Heart Disease, Old Age_
Circumstances of the Death
On the Ist October 2017, the deceased'$ family called Shropdoc twice at 09.18 hours and 14.32 hours. On the second occasion urgent care practitioners were required and attended the deceased within 90 minutes. The deceased was assessed as not requiring hospital admission. The deceased's family made a 999 call to West Midlands Ambulance Service at 21.02 hours, ambulance attended at 21.09 hours. At 21.13 hours the deceased had a EWS of 5. She arrived at The Princess Royal Hospital at 21.41 hours. She was triaged at 22.00 hours and had a EWS of 8. Sepsis was not deemed to be present: This was reviewed by a nurse and changed some 30 minutes later. That nurse spoke to a middle grade Emergency Department Doctor who authorised intravenous fluids to be administered. Her medical records were then placed into the wrong folder and she was not therefore reviewed by an Emergency Doctor until midnight when came on duty. There had only been two Doctors on duty to that as one reported in sick: Bloods had been taken at 22.15 hours but no blood cultures were obtained. The blood results were known at 22.41 hours, they indicated that sepsis was present and that her kidney had been damaged and that her prognosis was poor. urinary catheter was inserted at 01.00 hours Intravenous antibiotics were prescribed at 00.30 hours but the Ertapenem was not in stock and when some was located it was not administered until 02.55 hours. At no was oxygen administered At 03.48 hours the deceased suffered a peri-arrest and died at 05.40 hours. The dressings on her legs had remained in place all on the Ist October 2017,they were only removed at 02.20 hours on the Znd October 2017 s0 that an examination of them could take place_ they the prior drug point day
The care provided by The Princess Royal Hospital on their own admission was sub-optimal; there was delayed recognition by the triage system; guidelines concerning sepsis were not followed meaning time critical management of the condition was delayed; sepsis six care bundle was therefore not followed through as it should have been: Had it been followed through in compliance with the guidelines it would have been to her benefit; however she was S0 poorly upon admission that it would not have altered the eventually outcome, indeed it would have prolonged it.
The care provided by The Princess Royal Hospital on their own admission was sub-optimal; there was delayed recognition by the triage system; guidelines concerning sepsis were not followed meaning time critical management of the condition was delayed; sepsis six care bundle was therefore not followed through as it should have been: Had it been followed through in compliance with the guidelines it would have been to her benefit; however she was S0 poorly upon admission that it would not have altered the eventually outcome, indeed it would have prolonged it.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.