Lily Townsend
PFD Report
All Responded
Ref: 2017-0191
All 1 response received
· Deadline: 10 Aug 2017
Coroner's Concerns (AI summary)
Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk patient undergoing surgery without proper risk discussion or informed consent.
View full coroner's concerns
1. Evidence emerged during the inquest that during the preoperative assessment inadequate medical history was taken and there was a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension.
2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given.
3. The risks of the procedure may have been reduced by performing an un-cemented operation given the known potential cardiopulmonary complications of cement.
4. The Trust initiated an internal investigation and identified that the root causes were: a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk.
b) Consent process inadequate.
2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given.
3. The risks of the procedure may have been reduced by performing an un-cemented operation given the known potential cardiopulmonary complications of cement.
4. The Trust initiated an internal investigation and identified that the root causes were: a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk.
b) Consent process inadequate.
Responses
Action Taken
Recording 'do not resuscitate' orders on a specific computer system, with disciplinary action for deviation, became a requirement on August 1st. A safety summit was held, and a presentation was created to track service changes monthly. (AI summary)
Recording 'do not resuscitate' orders on a specific computer system, with disciplinary action for deviation, became a requirement on August 1st. A safety summit was held, and a presentation was created to track service changes monthly. (AI summary)
View full response
Dear Mr Siddique
Response to the Regulation 28 Report – the late Mrs Lily Townsend
I am in receipt of your Regulation 28 Report following the Inquest and your ruling on 12 June 2017, in respect of the late Lily Townsend. I should extend again the condolences of the Trust to Mrs Townsend’s family, to whom I am copying this letter.
The important issues you raise have been taken very seriously within the Trust. I attach a presentation by the relevant clinical team which sets out their promises to us about how they will change their service. This is being tracked each month by the Clinical Group Management team using a data scorecard (also attached).
The consultant body within orthopaedics, geriatric medicine and anaesthetics attended, with other professionals, a Safety Summit which I chaired. Here we discussed the issues which had given rise to your report, and the planned actions. The summit was also attended by our medical and nursing directors, and the non-executive chair of our Quality and Safety Committee. The Trust's Board are fully involved with the improvement required.
One issue you notified me about relates to our practice around high risk patients, where a ‘do not resuscitate order’ may be relevant. Since August 1st, recording such orders on a specific computer system within the Trust has become a requirement underpinned by disciplinary
2 | P a g e
action for deviation. This allows us to ensure the quality of each order is assessed. I should be clear that our audit data to date attests to good quality decision making and involvement but we are striving for excellence.
I anticipate the majority of the actions in the plan being complete by the end of October and will write to you again in November to update you on the status of our work.
Do contact me, or my colleague should this documentation give rise to questions or concerns.
Response to the Regulation 28 Report – the late Mrs Lily Townsend
I am in receipt of your Regulation 28 Report following the Inquest and your ruling on 12 June 2017, in respect of the late Lily Townsend. I should extend again the condolences of the Trust to Mrs Townsend’s family, to whom I am copying this letter.
The important issues you raise have been taken very seriously within the Trust. I attach a presentation by the relevant clinical team which sets out their promises to us about how they will change their service. This is being tracked each month by the Clinical Group Management team using a data scorecard (also attached).
The consultant body within orthopaedics, geriatric medicine and anaesthetics attended, with other professionals, a Safety Summit which I chaired. Here we discussed the issues which had given rise to your report, and the planned actions. The summit was also attended by our medical and nursing directors, and the non-executive chair of our Quality and Safety Committee. The Trust's Board are fully involved with the improvement required.
One issue you notified me about relates to our practice around high risk patients, where a ‘do not resuscitate order’ may be relevant. Since August 1st, recording such orders on a specific computer system within the Trust has become a requirement underpinned by disciplinary
2 | P a g e
action for deviation. This allows us to ensure the quality of each order is assessed. I should be clear that our audit data to date attests to good quality decision making and involvement but we are striving for excellence.
I anticipate the majority of the actions in the plan being complete by the end of October and will write to you again in November to update you on the status of our work.
Do contact me, or my colleague should this documentation give rise to questions or concerns.
Sent To
- Sandwell and West Birmingham Hospitals NHS Trust
Response Status
Linked responses
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56-Day Deadline
10 Aug 2017
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 25 April 2017, I commenced an investigation into the death of the late Mrs Lily Townsend. The investigation concluded at the end of the inquest on 12 June 2017. The conclusion of the inquest was a short narrative conclusion of:
“Died after developing a rare but recognised complication of pulmonary fat embolism due to bone cement implantation syndrome.”
The cause of death was:
1a Pulmonary Fat Embolism b Bone Cement Implantation Syndrome c II Ischaemic Heart Disease and Pulmonary Fibrosis
“Died after developing a rare but recognised complication of pulmonary fat embolism due to bone cement implantation syndrome.”
The cause of death was:
1a Pulmonary Fat Embolism b Bone Cement Implantation Syndrome c II Ischaemic Heart Disease and Pulmonary Fibrosis
Circumstances of the Death
i) Mrs Townsend had an unwitnessed fall at home in her bathroom on the evening of 11 February 2017 and was admitted to Sandwell Hospital on the 12 February. ii) She had a medical history including cancer, severe cardio pulmonary disease, atrial fibrillation and pulmonary fibrosis. A fractured neck of femur was diagnosed. iii) Inadequate medical history was taken during the preoperative assessment and a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension. iv) On the 13 February, she underwent cemented hemiarthoplasty and when the cement was applied her oxygen saturation and blood pressure dropped rapidly and despite attempts at resuscitation she was pronounced deceased at 1pm.
[IL1: PROTECT]
[IL1: PROTECT]
Action Should Be Taken
1. Given the finding of the recent audit (Assessment of documentation of risks for hip fracture patients June 2017) to check compliance that documentation of risk discussion has been completed. It is disappointing to note that it was only completed satisfactorily in 8 out of 18 patients. The overall documentation and risk discussion remains poor during both preoperative and post-operative phases. You may wish to consider setting up an urgent review of the issues identified and consider appropriate action to improve compliance.
Copies Sent To
Senior Coroner Black Country Area
[IL1: PROTECT] 3
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.