Peter O’Donnell
PFD Report
All Responded
Ref: 2018-0201
All 1 response received
· Deadline: 15 May 2018
Coroner's Concerns (AI summary)
Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and failed to report nurse misconduct, creating systemic safety risks.
View full coroner's concerns
During the Inquest evidence was heard that:-
1. Whilst an in-patient the care afforded to the deceased was consultant led. The consultant in question was an independent consultant orthopaedic surgeon who confirmed the absence of any formal agreement regarding the criteria in which he would be subsequently called into the hospital to undertake a review of his patient. The consultant maintained that it would be useful to have a document that detailed the circumstances of any future intervention. In the course of the inquest I was handed a copy of a report entitled “No Safety without Liability” written by the Centre for Health and the Public Interest (available at www.chpi.org.uk). Within that report is a recommendation that private hospital companies should directly employ surgeons, anaesthetists and physicians who work at their hospitals and should take on responsibility for monitoring their activities and appraising their performance. In this instance neither communication nor escalation procedures were documented.
2. A single Junior Doctor (Resident Medical Officer) was the sole Clinician providing post-operative care for patients. He was on duty 24/7 and asserted that a daily review of each patient would be adequate (although this would be a minimum and would depend on the condition of the individual patient). Both the monitoring and appraisal of each RMO remained with an outside Employment Agency rather than the private hospital in which they were based. Responsibility for training was similarly unclear.
3. Neither protocols nor procedures existed for the transfer of unwell patients to local acute hospitals. Following the death of Mr O’Donnell the Beaumont and local acute Hospital Trust liaised to formulate a proforma document which would detail the rationale for the transfer as well as including all relevant clinical information which would benefit the receiving Hospital. It is by no means certain that such procedures and documentation exist beyond this jurisdiction of Manchester West.
4. Private hospitals should be required to adhere to the same reporting requirements as NHS Hospitals in order to improve the chance of harm to patients being detected.
5. Following Mr O’Donnell’s death BMI Healthcare on behalf of the Beaumont Hospital instigated a root cause analysis investigation in the course of which it became clear that two registered General Nurses who were involved in the care afforded to Mr O’Donnell made a number of additions to both the observations chart and nursing notes after Mr O’Donnell had been transferred to the acute Hospital in direct contravention of Clause 10.3 within the Code detailing professional standards of practice and behaviour for Nurses and Midwives issued in 2015. Whilst the BMA instigated its own independent disciplinary investigation I believe that the Nurse’s actions should have been reported forthwith to the Nursing and Midwifery Council as I believe would be the case in the public sector. Reporting should be mandatory in the private hospital sector.
1. Whilst an in-patient the care afforded to the deceased was consultant led. The consultant in question was an independent consultant orthopaedic surgeon who confirmed the absence of any formal agreement regarding the criteria in which he would be subsequently called into the hospital to undertake a review of his patient. The consultant maintained that it would be useful to have a document that detailed the circumstances of any future intervention. In the course of the inquest I was handed a copy of a report entitled “No Safety without Liability” written by the Centre for Health and the Public Interest (available at www.chpi.org.uk). Within that report is a recommendation that private hospital companies should directly employ surgeons, anaesthetists and physicians who work at their hospitals and should take on responsibility for monitoring their activities and appraising their performance. In this instance neither communication nor escalation procedures were documented.
2. A single Junior Doctor (Resident Medical Officer) was the sole Clinician providing post-operative care for patients. He was on duty 24/7 and asserted that a daily review of each patient would be adequate (although this would be a minimum and would depend on the condition of the individual patient). Both the monitoring and appraisal of each RMO remained with an outside Employment Agency rather than the private hospital in which they were based. Responsibility for training was similarly unclear.
3. Neither protocols nor procedures existed for the transfer of unwell patients to local acute hospitals. Following the death of Mr O’Donnell the Beaumont and local acute Hospital Trust liaised to formulate a proforma document which would detail the rationale for the transfer as well as including all relevant clinical information which would benefit the receiving Hospital. It is by no means certain that such procedures and documentation exist beyond this jurisdiction of Manchester West.
4. Private hospitals should be required to adhere to the same reporting requirements as NHS Hospitals in order to improve the chance of harm to patients being detected.
5. Following Mr O’Donnell’s death BMI Healthcare on behalf of the Beaumont Hospital instigated a root cause analysis investigation in the course of which it became clear that two registered General Nurses who were involved in the care afforded to Mr O’Donnell made a number of additions to both the observations chart and nursing notes after Mr O’Donnell had been transferred to the acute Hospital in direct contravention of Clause 10.3 within the Code detailing professional standards of practice and behaviour for Nurses and Midwives issued in 2015. Whilst the BMA instigated its own independent disciplinary investigation I believe that the Nurse’s actions should have been reported forthwith to the Nursing and Midwifery Council as I believe would be the case in the public sector. Reporting should be mandatory in the private hospital sector.
Responses
Noted
The Department of Health acknowledges concerns regarding independent hospitals and refers to existing standards, CQC ratings, and quality monitoring data submissions, also noting the ongoing Paterson Inquiry looking into accountability and quality of care in the independent sector. (AI summary)
The Department of Health acknowledges concerns regarding independent hospitals and refers to existing standards, CQC ratings, and quality monitoring data submissions, also noting the ongoing Paterson Inquiry looking into accountability and quality of care in the independent sector. (AI summary)
View full response
Department of Health RE Your reference: MJLIYD/I04-18 15 916 ~01G Our reference: PFD 1125666 15 "7 .01B Mr Simon R Nelson HM Coroner s Court Paderborn House Howell Croft North Bolton BLI 1QY May 2018 Aelsa. for letter of 20 March to the Secretary of State for Health and Thank you cotithetdeath of Mr Peter O Donnell. am responding as Social Care about care quality and safety: Minister with responsibility for hospital saddened to read of the circumstances surrounding Mr O 'Donnelte I was very condolences to his family and loved ones 1 appreciate death: Please pass my this must be a difficult time for them raises several matters of concern and my officials have made Your Report Commission (CQC) and the Nursing and enquiries with the Care Quality Midwifery Council (NMC) in preparation of this reply: Iwould like to make clear that independent hospitals are expected t0 Firstly, Fundamental Standards for quality and safety %f care just aS any meet the same be aware that the Secretary of State other registered provider; Indeed,You may wrote to independent sector hospital provider chief executives on 7 May seeking their co-operation on & number of safety and quality issues' Patient gus beparamount in all healthcare settings which is why all NHS and safety independent hospitals are rated by the CQC https Lwww goyukgovene publicationspatienL-safely-leller-to-independenL-healthcare-previders patient
Indepondent hospitalsare required to submit the same quality and safety noeitorieg data for NHS patients a8 expected by NHS Qrustsy Fof eaenple; never events are reported to the strategic executive infomation and surgical outcomes are reported to the National Joint system (STEIS) would then be monitored as partfof the contractual Registry. Outcomes NHS. monitoring process with the This is not mastdatory for non-NHS patients and there is no other mandatory Daondtoring system in place for ijdependent healthcare senviocherHoandaeo,as Daeit O COohs inspection procesd it would expect providers to have developed their own robust internal systems to identify, monitor and mitigate risks and monitor quality of service provision: Iam advised that the CQC carried out an announced Healthcare; Beaumont inspection of BMI Hospital on 2 and 3 September 2015,and an unannounced visit On 17 September between 6 and 7.3Opm to check how patients were cared for out ofhours, The CQC carried out this inspection as part of its comprehensive inspection programme of independent healthcarea hospitals Overall, BMI Beaumont Hospitallwas rated as Good'_ The CQC 's inspection of this service included a review df and assessment and Tonitoring offpatientzisi GnclddPg aisadlation adffian escalation and transfer processes in case of emergency) apd monitoring of patient outcomes A of the report can be found at WWW_cgc OTg ukllocationL copy '1-428758526. Rcgdetetedproviders must notify the COC about certain changes; events and incidents that affect their service or the people who uselc This includes serious and death of a person usingkthe service. A full list of the notifications required can be found at WWW_cgclorg ! ukguidance-providers independentz acute-hospitals: Iam advised that BMI Beaumont Hospital submitted regarding the death of Mr 0 Donnell on 27 statutory notification responsible for this service January 2017. The CQC inspector contacted the registered manager to discuss the incedeat iaesheaiquiryas closed pending the outcome of the inquest had icrnalitbvessieationarinformationkfom both the investigationeandthe tnqdest will now be used as part of the CQC'$ monitoring intelligence in the the next inspection. planning of I can provide assurance that the reviews escalation and and protocols as part of its inspection process under transfer procedures Regulation 12: Safe care training levels; injury
Department of Health and Treatment; Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In accordance with Regulation 12 (2) (i) CQC would expect that where responsibility for the care and treatment of service users is shared with, Or transferred to, other persons, there are systems in place for working with such other persons to ensure that timely care planning takes place to ensure the health; safety and welfare of service users. The independent health care sector is diverse and many independent providers deliver a wide range of services for both adults and children; including specialist and enhanced healthcare in an array of settings and in a number of ways. However; we recognise that the sector delivers many of the same types of services as acute NHS providers, and is increasingly being commissioned to deliver services on behalf of the NHS. While the CQC $ regulatory model is tailored to each sector and type of service, it does also take into account the need to ensure providers are treated equally when delivering similar types of services and that all providers are regulated in an appropriate and proportionate way: This is critical to providing assurance about the quality and safety of these services CQC has therefore, where possible, aligned its regulatory model for the independent health sector with other sectors including the NHS acute and primary medical services_ The CQC published its analysis of the quality and safety of care provided by independent acute hospitals across England on 11 April. The report, The state of care in independent hospitals' is available at WWwcgC Org uklpublications/major-reportlstate-care-independent-acute_ hospitals; and provides for the first time a comprehensive picture of the quality of care provided: While the report found that the majority of independent acute hospitals are providing high quality care for patients, 41 per cent of hospitals were rated as requiring improvement and 1 per cent; inadequate; for safety: Relevant to the concerns of your Report, the CQC identified a lack of formalised governance procedures, meaning that hospitals were not effectively monitoring the work of consultants, and a failure to monitor clinical outcomes and to prepare for the possibility of clinical deterioration in a patient'$ condition: As outlined above, the CQC is working with providers through its inspections and enforcement powers to help independent hospitals understand where
improvements are needed and to hold them to account for delivering those improvements_ Also of importance to the matters of concern you raise is the Paterson Inquiry, set up following the conviction of the surgeon Ian Paterson, to learn lessons from Ian Paterson'$ malpractice and other past and current practices to enhance the safety and quality of care both in the independent sector and the NHS. The Paterson Inquiry will address issues relating to the conditions under which doctors provide services within independent hospitals, including levels of supervision The Terms of Reference include: 'A comparison of the accountability and responsibility for the safety and quality of care received between the independent sector and in the NHS; including the roles of hospital providers and others in appraising, reporting, considering concerns and monitoring aS regards healthcare professionals' activity levels, conduct and performance; And will consider; among other issues, the arrangements for assuring that healthcare professionals maintain appropriate professional standards and competence, including appraisal, revalidation, scope of practice, and the role of hospital providers, professional and quality regulators, and other oversight bodies The full Terms of Reference are available at wwwpatersoninquiry org uklterms-of-referencel We expect the Inquiry to report and make its recommendations in the summer of 2019. Given the relevance of the concerns you have raised, you may wish to share these with the Paterson Inquiry: The contact details for the Inquiry are: Email: enquiries@patersoninquiry org uk Tel. no: 0207 972 1295 Or you can write to the Inquiry at PO Box 879,LS] 9RZ Finally, with regard to your last area of concern, pertaining to the referral of registered nurses to the NMC, I can confirm that the NMC $ guidance applies to all employers of nurses and midwives, whether NHS Or independent sector: It is for the employer to decide Whether to make a referral based on the circumstances of the case. Referrals must be made if the employer believes the conduct competence, health or character of a nurse Or midwife always
Department of Health presents a risk to patient safety. Further details can be found at Wwwnmcorg uklconcerns-nurses-midwives/dealing-concerns/services employers/ [ that you find this information helpful. Thank you for bringing the circumstances of Mr 0 'Donnell's death to my attention. CAROLINE DINENAGE MP hope `
Indepondent hospitalsare required to submit the same quality and safety noeitorieg data for NHS patients a8 expected by NHS Qrustsy Fof eaenple; never events are reported to the strategic executive infomation and surgical outcomes are reported to the National Joint system (STEIS) would then be monitored as partfof the contractual Registry. Outcomes NHS. monitoring process with the This is not mastdatory for non-NHS patients and there is no other mandatory Daondtoring system in place for ijdependent healthcare senviocherHoandaeo,as Daeit O COohs inspection procesd it would expect providers to have developed their own robust internal systems to identify, monitor and mitigate risks and monitor quality of service provision: Iam advised that the CQC carried out an announced Healthcare; Beaumont inspection of BMI Hospital on 2 and 3 September 2015,and an unannounced visit On 17 September between 6 and 7.3Opm to check how patients were cared for out ofhours, The CQC carried out this inspection as part of its comprehensive inspection programme of independent healthcarea hospitals Overall, BMI Beaumont Hospitallwas rated as Good'_ The CQC 's inspection of this service included a review df and assessment and Tonitoring offpatientzisi GnclddPg aisadlation adffian escalation and transfer processes in case of emergency) apd monitoring of patient outcomes A of the report can be found at WWW_cgc OTg ukllocationL copy '1-428758526. Rcgdetetedproviders must notify the COC about certain changes; events and incidents that affect their service or the people who uselc This includes serious and death of a person usingkthe service. A full list of the notifications required can be found at WWW_cgclorg ! ukguidance-providers independentz acute-hospitals: Iam advised that BMI Beaumont Hospital submitted regarding the death of Mr 0 Donnell on 27 statutory notification responsible for this service January 2017. The CQC inspector contacted the registered manager to discuss the incedeat iaesheaiquiryas closed pending the outcome of the inquest had icrnalitbvessieationarinformationkfom both the investigationeandthe tnqdest will now be used as part of the CQC'$ monitoring intelligence in the the next inspection. planning of I can provide assurance that the reviews escalation and and protocols as part of its inspection process under transfer procedures Regulation 12: Safe care training levels; injury
Department of Health and Treatment; Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In accordance with Regulation 12 (2) (i) CQC would expect that where responsibility for the care and treatment of service users is shared with, Or transferred to, other persons, there are systems in place for working with such other persons to ensure that timely care planning takes place to ensure the health; safety and welfare of service users. The independent health care sector is diverse and many independent providers deliver a wide range of services for both adults and children; including specialist and enhanced healthcare in an array of settings and in a number of ways. However; we recognise that the sector delivers many of the same types of services as acute NHS providers, and is increasingly being commissioned to deliver services on behalf of the NHS. While the CQC $ regulatory model is tailored to each sector and type of service, it does also take into account the need to ensure providers are treated equally when delivering similar types of services and that all providers are regulated in an appropriate and proportionate way: This is critical to providing assurance about the quality and safety of these services CQC has therefore, where possible, aligned its regulatory model for the independent health sector with other sectors including the NHS acute and primary medical services_ The CQC published its analysis of the quality and safety of care provided by independent acute hospitals across England on 11 April. The report, The state of care in independent hospitals' is available at WWwcgC Org uklpublications/major-reportlstate-care-independent-acute_ hospitals; and provides for the first time a comprehensive picture of the quality of care provided: While the report found that the majority of independent acute hospitals are providing high quality care for patients, 41 per cent of hospitals were rated as requiring improvement and 1 per cent; inadequate; for safety: Relevant to the concerns of your Report, the CQC identified a lack of formalised governance procedures, meaning that hospitals were not effectively monitoring the work of consultants, and a failure to monitor clinical outcomes and to prepare for the possibility of clinical deterioration in a patient'$ condition: As outlined above, the CQC is working with providers through its inspections and enforcement powers to help independent hospitals understand where
improvements are needed and to hold them to account for delivering those improvements_ Also of importance to the matters of concern you raise is the Paterson Inquiry, set up following the conviction of the surgeon Ian Paterson, to learn lessons from Ian Paterson'$ malpractice and other past and current practices to enhance the safety and quality of care both in the independent sector and the NHS. The Paterson Inquiry will address issues relating to the conditions under which doctors provide services within independent hospitals, including levels of supervision The Terms of Reference include: 'A comparison of the accountability and responsibility for the safety and quality of care received between the independent sector and in the NHS; including the roles of hospital providers and others in appraising, reporting, considering concerns and monitoring aS regards healthcare professionals' activity levels, conduct and performance; And will consider; among other issues, the arrangements for assuring that healthcare professionals maintain appropriate professional standards and competence, including appraisal, revalidation, scope of practice, and the role of hospital providers, professional and quality regulators, and other oversight bodies The full Terms of Reference are available at wwwpatersoninquiry org uklterms-of-referencel We expect the Inquiry to report and make its recommendations in the summer of 2019. Given the relevance of the concerns you have raised, you may wish to share these with the Paterson Inquiry: The contact details for the Inquiry are: Email: enquiries@patersoninquiry org uk Tel. no: 0207 972 1295 Or you can write to the Inquiry at PO Box 879,LS] 9RZ Finally, with regard to your last area of concern, pertaining to the referral of registered nurses to the NMC, I can confirm that the NMC $ guidance applies to all employers of nurses and midwives, whether NHS Or independent sector: It is for the employer to decide Whether to make a referral based on the circumstances of the case. Referrals must be made if the employer believes the conduct competence, health or character of a nurse Or midwife always
Department of Health presents a risk to patient safety. Further details can be found at Wwwnmcorg uklconcerns-nurses-midwives/dealing-concerns/services employers/ [ that you find this information helpful. Thank you for bringing the circumstances of Mr 0 'Donnell's death to my attention. CAROLINE DINENAGE MP hope `
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
15 May 2018
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 the 25th of January 2017 I commenced an investigation into the death of Peter O’Donnell, aged 77 years. The investigation concluded at the end of the inquest on the 13th March 2018. The conclusion of the Inquest was:-
Against a background of extensive pre-existing natural disease Peter O’Donnell died from a recognised complication of necessary surgical intervention. The medical cause of death was certified as:-
Ia Multiple organ failure Ib Sepsis Ic Hospital acquired pneumonia following hip replacement II Ischaemic heart disease
Against a background of extensive pre-existing natural disease Peter O’Donnell died from a recognised complication of necessary surgical intervention. The medical cause of death was certified as:-
Ia Multiple organ failure Ib Sepsis Ic Hospital acquired pneumonia following hip replacement II Ischaemic heart disease
Circumstances of the Death
The deceased was admitted to the private Beaumont Hospital on the 14th January 2017 for an elective right total hip replacement which proceeded uneventfully. On the morning of the 16th January he presented with symptoms of a chest infection. Thereafter by reason of ineffective communication between professionals; irregular observations and inadequate documentation opportunities to escalate his care were missed. Antibiotic therapy was significantly delayed. The deceased’s subsequent deterioration in particular from shortly before midnight on the 17th January 2017 went unrecognised until the decision to transfer him to the Royal Bolton Hospital was made at approximately 11:00 hours on the 18th January 2017. He suffered a cardiac arrest at 20:25 hours that day following which he did not regain consciousness with the fact of death being confirmed at 16:20 hours on the 21st January 2017.
Copies Sent To
2. Fieldings Porter Solicitors
3. BMI Healthcare
4. NES Healthcare
5. Royal Bolton Hospital
7. Centre for Health and Public Interest
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.