Milly Zemmel
PFD Report
All Responded
Ref: 2016-0139
All 1 response received
· Deadline: 3 Jun 2016
Coroner's Concerns (AI summary)
There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an unsupervised, vulnerable patient falling. The internal investigation was also inadequate.
View full coroner's concerns
In the circumstances it is my statutory to report to you: In circumstances it is my statutory duty to report to you: 1 _ The Trust's own internal investigative procedures were demonstrably inadequate because the internal hospital investigation did not fully and properly identify the gross failure to provide the deceased with the basic medical care which her condition obviously required on the morning of March 2015. The full particulars only became apparent when evidence was heard at the inquest and the records were checked: The gravity of the failings in care had not been properly identified. There have been failures to assess and correctly apply the then existing falls risk policy:
3. There was a failure to escalate the requirement for a clinical review following fall on 21 February 2015 and nor was this identified at handovers on several occasions There was a gross failure to initiate appropriate one to one supervision and observations for the deceased from the early hours of the morning on March 2015. In addition there was a failure to ensure that important clinical information about the deceased' s condition was handed over to the next shift. Nor did the next shift nurse in charge ensure that the deceased's records were checked to find out what the up to date information on the situation was Consequently the deceased,who was suffering an duty the her acute confusional state , and who was blind was left unsupervised for several hours leading her to have fall and suffer a serious injury which caused or contributed to her death.
3. There was a failure to escalate the requirement for a clinical review following fall on 21 February 2015 and nor was this identified at handovers on several occasions There was a gross failure to initiate appropriate one to one supervision and observations for the deceased from the early hours of the morning on March 2015. In addition there was a failure to ensure that important clinical information about the deceased' s condition was handed over to the next shift. Nor did the next shift nurse in charge ensure that the deceased's records were checked to find out what the up to date information on the situation was Consequently the deceased,who was suffering an duty the her acute confusional state , and who was blind was left unsupervised for several hours leading her to have fall and suffer a serious injury which caused or contributed to her death.
Responses
Action Taken
The Trust has revised its Incident Reporting and Investigation Policy, launched an Enhanced Patient Observation Policy, and will include failure to escalate lack of medical review in the Lessons Learned Bulletin. Staff will use the SBAR communication tool. (AI summary)
The Trust has revised its Incident Reporting and Investigation Policy, launched an Enhanced Patient Observation Policy, and will include failure to escalate lack of medical review in the Lessons Learned Bulletin. Staff will use the SBAR communication tool. (AI summary)
View full response
Dear Mr Meadows Re: Inquest following the death of Mrs Milly Zemmel held on 29th March 2016 Please find the Trust's response to the recent Regulation 28: Report to Prevent Future Deaths served on the Trust on 7 April 2016 following the Inquest into the death of Mrs Milly Zemmel. The Trust response and action taken to address the concerns that you raised are detailed below: Background Mrs Zemmel was transferred to Ward E5 on gth February 2015. Ward ES was a temporary ward opened in response to increased demand due to seasonal pressures at the beginning of 2015. The Trust should consider reviewing their own internal investigation systems and ensure that are transparent, thorough, appropriately candid and up to date Those involved the deceased's care and management or who have line management responsibility should not form part of any investigative team: was recognised early 2015 that the Trust need make improvements how investigations were conducted within the organisation: An external review of serious incident investigations was commissioned by the former Chief Executive and following this review the Trust instigated number of actions: The Trust revised and launched a new policy and procedures for investigation called the Incident Reporting and Investigation Policy, including the Serious Incident Framework (EDQOO8 V6.4) in June 2015. This has provided clearer guidance for managers undertaking investigation: The policy provides clear guidance on the grading; level and type of investigation required for all incidents including those for serious incidents_ These are now investigated by a team independent of the clinical area where the incident occurred and involve senior clinical staff who have the expertise and knowledge to undertake the investigations May they
Pridein Ossyxfk" The Pennine Acute Hospitals NS Pennine Conyci"e NNS Tres A two day programme of root cause analysis training was commissioned by an external company specialising in root cause analysis (RCA) training and 103 staff, including senior clinicians and managers were trained during 2015/16. In addition the Trust delivered training on of Candour (being open) to ensure that patients and families receive support and feedback when serious incident investigation is commenced. An internal programme of investigation training will continue throughout 2016/17 to ensure that the quality and breadth of Trust investigations continues to improve To accompany the RCA training programme the Clinical Governance team have also developed an investigation toolkit that covers all aspects of investigations and advice preparing and investigation reports Please see Appendix for the full Policy Incident Reporting and Investigation including the Serious Incident Framework Whilst the introduction of new falls policy commendable and be applauded, there was failure in nursing and clinical hand-over, escalation and management which should not have been allowed occur This was part basic nursing and clinical management: Trust should consider reviewing the hand-over and escalation policies and protocols so as to ensure fail-safe system. The Trust has piloted and now introduced a 'Safety Huddle' at the commencement of each ward and departmental shift which includes the discussion and handover of any recent incidents as well as safety issues relating to patients. This includes a prompt for discussion of any patients who will require additional observation or enhanced supervision as part of their care This allows nursing staff to report on any unexpected and significant events involving patients and helps them to proactively plan and agree how to resolve them. The policy is within Appendix 2 Safety Huddle document. The Trust launched policy for Clinical Communication and Handover in September 2015 which includes handover documentation templates with more robust information for recording safety concers such as patient who may be at risk of falls information and standard framework for escalating concerns about patient. The policy also includes the standard required for doctor to doctor handovers including for patients who have been referred and who need to be assessed: The policy has been disseminated across the clinical teams in the Trust and the senior nursing team undertake quarterly audits to assess the quality ad level of compliance. This policy is within Appendix 3_ Clinical Communication and Handover Policy: The introduction of the New Falls Policy and Enhanced Patient Observation Policy The new Fallsafe Policy for the prevention and management of in-patient falls was introduced in April 2016; this includes newly launched tools for assessment, care planning and a care bundle_ As part of the launch, training was included using the Fallsafe resources produced by the Royal College of Physicians and is available to all staff. The Trust has now employed two Specialist Practitioners for falls to further.enhance ad develop the systems and processes for the education and training of staff. Part of their work will be to develop the processes for patient risk assessment and for auditing the implementation and effectiveness of the policy in clinical areas The FallSafe Policy is in Appendix and the Fallsafe staff information booklet is within at Appendix 5. The Enhanced Patient Observation Policy was also introduced in February 2016 to ensure patient safety and to help provide the appropriate level of supervision and observation for adult in-patients. This policy provides advice and support to staff on the different requirements and needs of patients who require observation. This can be found in Appendix 6 Enhanced Patient Observation Policy: Duty writing Policy, The
Pridein (amnon The Pennine Acute Hospitals NHS] Rcy >R Pennine (0pneso+ NNS Trusl Dissemination of Lessons Learned Failure to act and escalate the lack of medical review will be included in the Lessons Learned Bulletin within the Medical Division and disseminated to all wards and departments across the division_ The learning for nursing staff is to escalate to the medical team and in the first instance to the registrar and then consultant or on call Consultant, with assistance if required, from within the senior nursing site team or on calll bleep holder out of hours to ensure that any request for urgent review occurs_ Staff will be required to use the communication handover SBAR tool (situation, background, assessment recommendation) support any communication_ This is contained within the Clinical Communication Handover Policy: sincerely hope that the above response addresses your concerns and provides you and Mrs Zemmels family with the assurance that we have addressed the learning following the inquest and our own investigation: Should you require any further information then please do not hesitate t0 contact me_ take this opportunity to again convey the Trust's sincere apologies and condolences to the family of Mrs Zemmel.
Pridein Ossyxfk" The Pennine Acute Hospitals NS Pennine Conyci"e NNS Tres A two day programme of root cause analysis training was commissioned by an external company specialising in root cause analysis (RCA) training and 103 staff, including senior clinicians and managers were trained during 2015/16. In addition the Trust delivered training on of Candour (being open) to ensure that patients and families receive support and feedback when serious incident investigation is commenced. An internal programme of investigation training will continue throughout 2016/17 to ensure that the quality and breadth of Trust investigations continues to improve To accompany the RCA training programme the Clinical Governance team have also developed an investigation toolkit that covers all aspects of investigations and advice preparing and investigation reports Please see Appendix for the full Policy Incident Reporting and Investigation including the Serious Incident Framework Whilst the introduction of new falls policy commendable and be applauded, there was failure in nursing and clinical hand-over, escalation and management which should not have been allowed occur This was part basic nursing and clinical management: Trust should consider reviewing the hand-over and escalation policies and protocols so as to ensure fail-safe system. The Trust has piloted and now introduced a 'Safety Huddle' at the commencement of each ward and departmental shift which includes the discussion and handover of any recent incidents as well as safety issues relating to patients. This includes a prompt for discussion of any patients who will require additional observation or enhanced supervision as part of their care This allows nursing staff to report on any unexpected and significant events involving patients and helps them to proactively plan and agree how to resolve them. The policy is within Appendix 2 Safety Huddle document. The Trust launched policy for Clinical Communication and Handover in September 2015 which includes handover documentation templates with more robust information for recording safety concers such as patient who may be at risk of falls information and standard framework for escalating concerns about patient. The policy also includes the standard required for doctor to doctor handovers including for patients who have been referred and who need to be assessed: The policy has been disseminated across the clinical teams in the Trust and the senior nursing team undertake quarterly audits to assess the quality ad level of compliance. This policy is within Appendix 3_ Clinical Communication and Handover Policy: The introduction of the New Falls Policy and Enhanced Patient Observation Policy The new Fallsafe Policy for the prevention and management of in-patient falls was introduced in April 2016; this includes newly launched tools for assessment, care planning and a care bundle_ As part of the launch, training was included using the Fallsafe resources produced by the Royal College of Physicians and is available to all staff. The Trust has now employed two Specialist Practitioners for falls to further.enhance ad develop the systems and processes for the education and training of staff. Part of their work will be to develop the processes for patient risk assessment and for auditing the implementation and effectiveness of the policy in clinical areas The FallSafe Policy is in Appendix and the Fallsafe staff information booklet is within at Appendix 5. The Enhanced Patient Observation Policy was also introduced in February 2016 to ensure patient safety and to help provide the appropriate level of supervision and observation for adult in-patients. This policy provides advice and support to staff on the different requirements and needs of patients who require observation. This can be found in Appendix 6 Enhanced Patient Observation Policy: Duty writing Policy, The
Pridein (amnon The Pennine Acute Hospitals NHS] Rcy >R Pennine (0pneso+ NNS Trusl Dissemination of Lessons Learned Failure to act and escalate the lack of medical review will be included in the Lessons Learned Bulletin within the Medical Division and disseminated to all wards and departments across the division_ The learning for nursing staff is to escalate to the medical team and in the first instance to the registrar and then consultant or on call Consultant, with assistance if required, from within the senior nursing site team or on calll bleep holder out of hours to ensure that any request for urgent review occurs_ Staff will be required to use the communication handover SBAR tool (situation, background, assessment recommendation) support any communication_ This is contained within the Clinical Communication Handover Policy: sincerely hope that the above response addresses your concerns and provides you and Mrs Zemmels family with the assurance that we have addressed the learning following the inquest and our own investigation: Should you require any further information then please do not hesitate t0 contact me_ take this opportunity to again convey the Trust's sincere apologies and condolences to the family of Mrs Zemmel.
Sent To
- North Manchester General Hospital
Response Status
Linked responses
1 of 1
56-Day Deadline
3 Jun 2016
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 3 March 2015 commenced an investigation into the death of ZEMMEL, aged 89_ The investigation concluded at the end of the inquest on 29 March 2016. The cause of death was found to be: Ia Right upper lobe pneumonia Fractured neck of femur; chronic kidney failure Recurrent confusional state The conclusion of the inquest was Accidental Death contributed to by neglect:
Circumstances of the Death
The deceased, who was aged 89, and registered blind, lived in sheltered accommodation_ She had the benefit of carers who visited her regularly as well as family members. However; on 7 February 2015 she was feeling particularly unwell and an ambulance was called: She was admitted into North Manchester General Hospital (NMGH): She was initially seen and assessed in the Accident and Emergency Department: Following this she was admitted to Ward H3 where , despite being blind, she was assessed as not being at risk of falls. This was later acknowledged by_NMGHto_be_totally_incorrect and her care plan was not City: the Milly appropriately completed nor was her risk of falls correctly assessed: She suffered from chronic conditions, ischaemic heart disease , kidney disease , anaemia, gout and diverticular disease. Her presenting symptomology suggested that she may have suffered an injury to her elbow in a fall but she did not report had a fall: She was treated with supportive therapy but over the next few days suffered episodes of acute confusion and disorientation. She was transferred to Ward E5 on 9 February and her risk of falls was reassessed. She suffered further episodes of confusion and disorientation and it was suspected that she was suffering from a urinary tract infection. On 21 February 2015 the deceased suffered an apparently witnessed fall at her bedside. Initial nursing assessment detected no obvious injuries and she was assisted back to sit in her chair. A request for medical review was made and initial neurological observations were commenced_ No clinician attended to review her until she was seen on 25 February and this was not escalated appropriately by the nurse in charge of the ward on 21 February and nor was it noted or recognised when her care was handed over to a number of shifts thereafter. Between 21 February and 1 March 2015 it is recorded that the deceased was repeatedly confused and agitated. At about Sam on March 2015 it is recorded that she was suffering an acute confusional episode and requires one to one supervision She appeared to be hallucinating and had been in and out of bed constantly: Despite this no one to one supervision was initiated and there was no evidence that her deteriorating condition was handed over t0 the next shift starting at approximately 07.30am: She had previously been subject to a regime of two hourly checks, however; that moming she was not checked and was not subject to one to one supervision for several hours: At around 11.30am she was found on the by her bed after having had an un-witnessed fall: Subsequent investigations established that she had suffered a fracture of her left femur: Clinically it was decided that she was not fit enough for surgery and despite treatment her condition deteriorated and she died on 3 March 2015. Following the death of the deceased NMGH initiated an investigation into her fall on March 2015 and produced a template report; It concluded: "The patient has a poor standing balance , requiring assistance of one, and was suffering - acute delerium with history of impaired vision. Whilst the care plans and risk assessments were all in place there was a failure to consider a low rise bed, tab alarm or patient watch" The deceased was in fact totally blind and did not impaired vision: It was recognised that after having a fall at her bedside on 21 February 2015 she had not been clinically reviewed until 25 February and this had not been escalated or recognised bY anyone A number of action having floor from have recommendations were made The internal hospital investigation did not fully and properly identify the gross failure to provide the deceased with the basic medical care which her condition obviously required on the moming of March 2015. The full particulars only became apparent when evidence was heard at the inquest and the records were checked: The gravity of the failings in care had not been properly identified. Following the death of the deceased the Hospital Trust introduced a new risk falls policy and initiated training for staff.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action. In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action. The Trust should consider reviewing their own internal investigation systems and ensure that are transparent; thorough, appropriately candid and up to date. Those involved in the deceased's care and management or who line management responsibility should not form part of any investigative team.
2. Whilst the introduction of a new falls policy is commendable and to be applauded; there was failure in nursing and clinical hand-over, escalation and management which should not have been allowed to occur. This was part of basic nursing and clinical management: The Trust should consider reviewing the hand-over and escalation policies and protocols so as to ensure a fail safe system.
2. Whilst the introduction of a new falls policy is commendable and to be applauded; there was failure in nursing and clinical hand-over, escalation and management which should not have been allowed to occur. This was part of basic nursing and clinical management: The Trust should consider reviewing the hand-over and escalation policies and protocols so as to ensure a fail safe system.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.