David White
PFD Report
All Responded
Ref: 2015-0437
All 1 response received
· Deadline: 6 Jan 2016
Coroner's Concerns (AI summary)
Critical medication side effects causing confusion were unrecorded and unaddressed. Despite documented fall risks in nursing notes, adequate supervision was absent, and these notes were not reviewed or acted upon.
View full coroner's concerns
In the circumstances it is my statutory duty t0 report to you: (1) The effect of Heparin, in causing confusion; was not in the records, and therefore not acted upon: (2) Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place. One to one care had been in contemplation: (3) Whilst nursing notes were kept about the risks, the records were not reviewed and acted upon.
Responses
Action Taken
Staff have been reminded of the importance of documenting allergies and adverse effects, including in Renal Mortality and Morbidity meetings; the safety briefing during nursing handover will now include care plans for patients at risk of falls, daily auditing of nursing documentation will be carried out, and Multidisciplinary Team meetings on Ward 9F have been changed to earlier in the day. (AI summary)
Staff have been reminded of the importance of documenting allergies and adverse effects, including in Renal Mortality and Morbidity meetings; the safety briefing during nursing handover will now include care plans for patients at risk of falls, daily auditing of nursing documentation will be carried out, and Multidisciplinary Team meetings on Ward 9F have been changed to earlier in the day. (AI summary)
View full response
Dear Ma’am,
Inquest touching the death of David Alan White
I write in response to a Regulation 28, Report to Prevent Future Deaths, dated 11 November 2015, which was made at the conclusion of the inquest into the sad death of David White. Barts Health NHS Trust takes Coronial investigations very seriously and I am sorry you have had to make Preventing Future Death recommendations and I am grateful to you for highlighting your concerns.
I note David Alan White died after suffering a fractured neck of right femur following an unwitnessed fall on the ward and your concerns relate to the lack of nursing documentation and lack of care plan review relating to his mobility.
The concerns you have raised in the Preventing Future Death report are:
1. The effect of Heparin, in causing confusion, was not in the records, and therefore not acted upon.
2. Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place. One to one care had been in contemplation.
3. Whilst nursing notes were being kept about the risks, the records were not being reviewed and acted upon.
We have investigated the above concerns and I can confirm:
1. The members of staff have been reminded of the importance of adhering to the normal process of ‘documenting allergies and adverse effects’ regardless of how unique the reaction may be as in this case. This issue has also been discussed in the Renal Mortality and Morbidity meeting as a learning point for
all teams and members of staff on the importance of documenting drug- related issues and the escalation of this information to senior clinical staff.
2. The safety briefing during nursing handover is now to include a verbal handover of the care plans for patients assessed as at risk of falls to alert incoming staff members as to the risk and care plan.
It has been emphasised to all senior nursing staff that daily auditing of all nursing and falls risk documentation must be carried out. This will ensure that call bells are within reach of patients and that all assessments and any changes in care plans are highlighted in the medical records.
We have reviewed the escalation of our ‘Specials’ requests to Bank Partners so that patients can be appropriately monitored and supervised (one to one) when they are assessed as at risk of falls and/or confused. Site managers can now be contacted out of hours to ensure appropriate management of care.
3. Multidisciplinary Team meetings on Ward 9F have now been changed to earlier in the day to discuss patients and make effective action plans for patient at risk of falls. This meeting consists of medical/surgical teams, physiotherapy, Occupational Therapists and the Ward Nurse in charge and includes a medical handover to ensure communication of any deterioration overnight that could influence risk of falls, such as increased confusion.
A practice development team has been recruited to support ward staff in adhering to ward protocols and procedures including documentation, assessment of risks and communication. We also have facilitated training from the ‘Falls Lead’ for the Trust to re-train nurses regarding the fall procedure and management and this took place on 29 June 2015.
I am once again grateful to you for bringing this case to my attention and I hope this letter fully answers the concerns you have raised.
Inquest touching the death of David Alan White
I write in response to a Regulation 28, Report to Prevent Future Deaths, dated 11 November 2015, which was made at the conclusion of the inquest into the sad death of David White. Barts Health NHS Trust takes Coronial investigations very seriously and I am sorry you have had to make Preventing Future Death recommendations and I am grateful to you for highlighting your concerns.
I note David Alan White died after suffering a fractured neck of right femur following an unwitnessed fall on the ward and your concerns relate to the lack of nursing documentation and lack of care plan review relating to his mobility.
The concerns you have raised in the Preventing Future Death report are:
1. The effect of Heparin, in causing confusion, was not in the records, and therefore not acted upon.
2. Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place. One to one care had been in contemplation.
3. Whilst nursing notes were being kept about the risks, the records were not being reviewed and acted upon.
We have investigated the above concerns and I can confirm:
1. The members of staff have been reminded of the importance of adhering to the normal process of ‘documenting allergies and adverse effects’ regardless of how unique the reaction may be as in this case. This issue has also been discussed in the Renal Mortality and Morbidity meeting as a learning point for
all teams and members of staff on the importance of documenting drug- related issues and the escalation of this information to senior clinical staff.
2. The safety briefing during nursing handover is now to include a verbal handover of the care plans for patients assessed as at risk of falls to alert incoming staff members as to the risk and care plan.
It has been emphasised to all senior nursing staff that daily auditing of all nursing and falls risk documentation must be carried out. This will ensure that call bells are within reach of patients and that all assessments and any changes in care plans are highlighted in the medical records.
We have reviewed the escalation of our ‘Specials’ requests to Bank Partners so that patients can be appropriately monitored and supervised (one to one) when they are assessed as at risk of falls and/or confused. Site managers can now be contacted out of hours to ensure appropriate management of care.
3. Multidisciplinary Team meetings on Ward 9F have now been changed to earlier in the day to discuss patients and make effective action plans for patient at risk of falls. This meeting consists of medical/surgical teams, physiotherapy, Occupational Therapists and the Ward Nurse in charge and includes a medical handover to ensure communication of any deterioration overnight that could influence risk of falls, such as increased confusion.
A practice development team has been recruited to support ward staff in adhering to ward protocols and procedures including documentation, assessment of risks and communication. We also have facilitated training from the ‘Falls Lead’ for the Trust to re-train nurses regarding the fall procedure and management and this took place on 29 June 2015.
I am once again grateful to you for bringing this case to my attention and I hope this letter fully answers the concerns you have raised.
Sent To
- Barts Health NHS Trust
Response Status
Linked responses
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56-Day Deadline
6 Jan 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
Circumstances of the Death
Mr White was admitted t0 the Royal London Hospital on 11 June 2015, where he remained until his death on 26" June. The original admission followed a presentation to the GP with significant pain from his arteral vascular disease on 4 June. On admission to hospital his Warfarin was changed to Heparin, and the family informed the nurses that this had led to confusion and hallucinations for Mr White On 12 June 2015 the hospital records demonstrate that Mr White had been risk assessed for mobility, and that the following actions had been agreed:
1. Call bell to be within reach
2. Supervised transfers Physiotherapy and Occupational Therapy At 21.40 hours on 18 June 2015 Mr White sustained an unwitnessed fall on the ward, He said that he fell backwards onto his bed when reaching for a urine bottle. He was not injured: His care plan was revlewed and the bedsides ralls decision was reviewed, At 08.45 hours on 19 June 2015 Mr White sustained another unwitnessed fall, He was found lying on the floor; He explained that he had slipped when attempting t0 get something out of the bedside locker X-rays revealed & right hip and right shouider fracture but did not identify fractured ribs,predomlnantlyon his right side
On 21 June 2015 he underwent emergency surgery for the fractured right neck Of femur. Following surgery he was admitted to (he intensive care unit where he remained intubated and ventilated, in addition to on a Hemofilter: On 24 June 2015 he was stepped down to the Renal High Dependency unit, but remained unwell with a likely infected dialysis catheter_ He died on 26 June 2015 at 21.55 hours_
1. Call bell to be within reach
2. Supervised transfers Physiotherapy and Occupational Therapy At 21.40 hours on 18 June 2015 Mr White sustained an unwitnessed fall on the ward, He said that he fell backwards onto his bed when reaching for a urine bottle. He was not injured: His care plan was revlewed and the bedsides ralls decision was reviewed, At 08.45 hours on 19 June 2015 Mr White sustained another unwitnessed fall, He was found lying on the floor; He explained that he had slipped when attempting t0 get something out of the bedside locker X-rays revealed & right hip and right shouider fracture but did not identify fractured ribs,predomlnantlyon his right side
On 21 June 2015 he underwent emergency surgery for the fractured right neck Of femur. Following surgery he was admitted to (he intensive care unit where he remained intubated and ventilated, in addition to on a Hemofilter: On 24 June 2015 he was stepped down to the Renal High Dependency unit, but remained unwell with a likely infected dialysis catheter_ He died on 26 June 2015 at 21.55 hours_
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe you and your organisation have the power t0 take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.