Colin Moulton
PFD Report
Partially Responded
Ref: 2015-0267
Coroner's Concerns (AI summary)
Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the hospital of their presence when responding to a patient already on hospital grounds, missing a crucial connection.
View full coroner's concerns
being being
the my opinion there circumstances it is my statutory to report to you: When Mr Moulton was admitted to A & E on the 13th February 2013, critical information conveyed by means of a verbal handover from the paramedic to the was Following this incident, Pennine Acute Trust now receiving triage nurse: requires the receiving triage nurse to have access to and have sight of the paramedic pro-forma with the additional actions be documented It would be helpful if requirement that those an additional copy of the paramedic pro-forma could be given to and remain with the receiving nurse At approximately Spm on the 13"h February 2013, a number of administrative staff, whilst home Saw Colin Moulton within the hospital grounds near to the Irwell Unit. en-route be in difficulty' One of the staff members called for perceived him to the assistance of an ambulance which attended and the paramedics on board apparently were unable to locate Mr Moulton; Had the Ambulance Trust notified the Hospital Trust of their presence within the hospital grounds, thas have tied in with earlier concerns in relation to Mr Moulton of which the may Ambulance Trust is requested to consider Hospital Trust was aware_ whether in the future, third parties such as Hospital Trusts might be notified in such circumstances.
the my opinion there circumstances it is my statutory to report to you: When Mr Moulton was admitted to A & E on the 13th February 2013, critical information conveyed by means of a verbal handover from the paramedic to the was Following this incident, Pennine Acute Trust now receiving triage nurse: requires the receiving triage nurse to have access to and have sight of the paramedic pro-forma with the additional actions be documented It would be helpful if requirement that those an additional copy of the paramedic pro-forma could be given to and remain with the receiving nurse At approximately Spm on the 13"h February 2013, a number of administrative staff, whilst home Saw Colin Moulton within the hospital grounds near to the Irwell Unit. en-route be in difficulty' One of the staff members called for perceived him to the assistance of an ambulance which attended and the paramedics on board apparently were unable to locate Mr Moulton; Had the Ambulance Trust notified the Hospital Trust of their presence within the hospital grounds, thas have tied in with earlier concerns in relation to Mr Moulton of which the may Ambulance Trust is requested to consider Hospital Trust was aware_ whether in the future, third parties such as Hospital Trusts might be notified in such circumstances.
Responses
Noted
The Department of Health acknowledges the concerns, noting local resolution and NWAS response. They provide national context including handover procedures, NHS England review of urgent and emergency care, enhanced summary care records, and the NMC's role in regulating nurses. (AI summary)
The Department of Health acknowledges the concerns, noting local resolution and NWAS response. They provide national context including handover procedures, NHS England review of urgent and emergency care, enhanced summary care records, and the NMC's role in regulating nurses. (AI summary)
View full response
From Ben Gummer MP Parliamentary Under Secretary of State for Care Quality Department Richmond House of Health 79 Whitehall London POCS 949547 SWIA ZNS Tel: 020 7210 4850 Mr; S. Nelson Senior Coroner The Phoenix Centre 2 6 AUg 2015 Church Street Heywood OLIO ILR U Aeks~ Thank you for your letter of 10h July 2015 following the inquest into the death of Mr Moulton. I was very sorry to hear f Mr Moulton's death and wish to extend my sincere condolences to his family: You have two main concerns in this case the first focusses on the ineffective communication between paramedic and nursing staff during the handover of Mr Moulton to A&E at Fairfield General Hospital (FGH): You state that this resulted in Mr Moulton being incorrectly triaged by the nursing staff and not receiving the most effective care: The second concern is over the lack of communication between the North West Ambulance Service (NWAS) and the Hospital Trust; when NWAS paramedics were called to provide assistance to Mr Moulton after he had been seen in difficulty in the grounds of the Hospital. [consider that both of your concerns are for local comment and resolution and I note that you have sent a copy of your report to the NWAS. I am aware that NWAS has already responded, addressing the issues you raise and asking that you redirect your specific concers to FGH for its consideration also. Further to this however; I am able to provide some relevant comment and guidance from a national perspective, which I hope you will find of use. Regarding your first concern, you point out that the Trust has now implemented improved handover procedures between paramedics and A&E staff which should ensure that the triage nurse sees any patient notes made by the paramedics and documents this action. However; you suggest that this could be further improved if the triage staff could, not only see but retain a copy of the paramedic notes Lz
NWAS has advised that its staff always leave a patient report form (PRF) at every hospital following patient transfer: A copy of this form also remains with the 'patient following admission: FGH has very specific patient handover procedures which require NWAS to leave a copy of the PRF with the hospital receptionist for placing with hospital documentation which is subsequently passed to the triage nurse once the patient has been booked in. A verbal handover of the patient is also provided to the triage nurse. Such robust procedures should ensure that FGH staff have access to important patient information whenever required: As the above has demonstrated, the actual detail of patient handover processes and procedures are a matter for each local Trust to decide. However; I can assure you that the Department of Health does expect all ambulance trusts to have effective clinical handover procedures in place with local acute trusts. This includes conveying information such as the patient's vital signs, history, injuries, name and age and documenting this action: In addition, the Royal College of Physicians, on behalf of NHS England and the Health and Social Care Information Centre; has prepared, "Professional guidance on the structure and content of ambulance records" Such records should include relevant clinical risk factors, presenting complaints 0r issues and safety alerts. All ambulance trusts are currently working to embed these standards into operational practice. copy of the guidance can be accessed from: http:/Lwww england nhs uklwp-content/uploads/2014/12/amblnce-rec-guid pdf In addition; NHS England'$ review of urgent and emergency care proposes a fundamental shift in the way urgent and emergency care services are provided: Their vision is to deliver more emergency care closer to home, in centres with the very best facilities and expertise, thereby helping to avoid unnecessary journeys or stays in, hospital: For this vision to be successful there needs to be effective, timely and appropriate transfer of patient inforation that follows the patient through the healthcare system. NHS England is working with partners to develop an enhanced summary care record to enable greater access to patient care plans, including end of life care records, special patient notes and mental health crisis notes triage to, key _
Inote that this case also raises issues about the standard of nursing care; which; in this instance, you consider amounted to neglect Whilst I cannot comment personally on a matter which is for the local Trust to address, I can confirm that all nurses must register with the Nursing and Midwifery Council (NMC) and meet set professional standards so are fit for practise in the UK. All registered nurses are expected to be familiar with and to uphold the standards in the NMC's publication: The Code: Professional standards of practice and behaviour for nurses and midwives. If an allegation is made about a nurse who may not meet the professional standards required in the UK, as set out in The Code; the NMC has a to investigate and, where necessary, take action to safeguard the health and well-being of the public In serious cases this action can include removing the nurse from the NMC $ register thereby preventing them from practising in the UK. Iam grateful to you for bringing the circumstances of Mr Moulton's death to my attention and hope that yof find this reply helpful: Il BEN GUMMER they duty
NWAS has advised that its staff always leave a patient report form (PRF) at every hospital following patient transfer: A copy of this form also remains with the 'patient following admission: FGH has very specific patient handover procedures which require NWAS to leave a copy of the PRF with the hospital receptionist for placing with hospital documentation which is subsequently passed to the triage nurse once the patient has been booked in. A verbal handover of the patient is also provided to the triage nurse. Such robust procedures should ensure that FGH staff have access to important patient information whenever required: As the above has demonstrated, the actual detail of patient handover processes and procedures are a matter for each local Trust to decide. However; I can assure you that the Department of Health does expect all ambulance trusts to have effective clinical handover procedures in place with local acute trusts. This includes conveying information such as the patient's vital signs, history, injuries, name and age and documenting this action: In addition, the Royal College of Physicians, on behalf of NHS England and the Health and Social Care Information Centre; has prepared, "Professional guidance on the structure and content of ambulance records" Such records should include relevant clinical risk factors, presenting complaints 0r issues and safety alerts. All ambulance trusts are currently working to embed these standards into operational practice. copy of the guidance can be accessed from: http:/Lwww england nhs uklwp-content/uploads/2014/12/amblnce-rec-guid pdf In addition; NHS England'$ review of urgent and emergency care proposes a fundamental shift in the way urgent and emergency care services are provided: Their vision is to deliver more emergency care closer to home, in centres with the very best facilities and expertise, thereby helping to avoid unnecessary journeys or stays in, hospital: For this vision to be successful there needs to be effective, timely and appropriate transfer of patient inforation that follows the patient through the healthcare system. NHS England is working with partners to develop an enhanced summary care record to enable greater access to patient care plans, including end of life care records, special patient notes and mental health crisis notes triage to, key _
Inote that this case also raises issues about the standard of nursing care; which; in this instance, you consider amounted to neglect Whilst I cannot comment personally on a matter which is for the local Trust to address, I can confirm that all nurses must register with the Nursing and Midwifery Council (NMC) and meet set professional standards so are fit for practise in the UK. All registered nurses are expected to be familiar with and to uphold the standards in the NMC's publication: The Code: Professional standards of practice and behaviour for nurses and midwives. If an allegation is made about a nurse who may not meet the professional standards required in the UK, as set out in The Code; the NMC has a to investigate and, where necessary, take action to safeguard the health and well-being of the public In serious cases this action can include removing the nurse from the NMC $ register thereby preventing them from practising in the UK. Iam grateful to you for bringing the circumstances of Mr Moulton's death to my attention and hope that yof find this reply helpful: Il BEN GUMMER they duty
Sent To
- Department of Health and Social Care
- North West Ambulance Service
Response Status
Linked responses
1 of 3
56-Day Deadline
4 Sep 2015
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 20th February 2013 commenced an investigation into the death of Colin Moulton for whom the cause of death was confirmed at Inquest at that of 1a) Bronchopneumonia with Alcoholic Liver Disease and Ischaemic Heart Disease, whilst not causative of death, all Hypothermia; factors. contributory At an Inquest hearing on the 25" June 2015, the Inquest was concluded with the following narrative 'Colin Moulton was discovered deceased within 25 feet of the perimeter wall of the Irwell Unit within the grounds of Fairfield General Hospital Bury shortly after 9am on the 14" February 2013 He had been admitted to the Accident ad Emergency Department of Fairfield General before 16:OOhrs on the 13th February: Whilst en-route to the Accident and shortly on the 13th February, paramedics observed that Mr Moulton Emergency Department was clearly unwell, suffering from abdominal pains and tachycardia and was becoming increasingly confused_ By reason of ineffective communication between paramedic and nursing staff, Mr Moulton was incorrectly triaged and accorded a lower priority than was appropriate Crucially, Mr Moulton'$ confusion wvent unrecognised with the result that when he attempted to leave the department; there formal capacity was no assessment; no discussions to involve clinician; no consideration of the involvement of 3 member of the security staff and no formal documentation which completed-all of amounted to sub-optimal nursing care. The evidence does not show whether Mr Moulton would have remained within the department had the correct procedures been followed but likely than not, the provisions of the Trust's missing person policy would have been more reason of the missed opportunities to render effective care, Mr Moulton'$ invoked. By death was contributed to by neglect_
Circumstances of the Death
As above
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe each of the power to take such action. you respectively have
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Improve LAS procedures for timing and recording ambulance whereabouts
Fennell Inquiry
Ambulance Handover Delays
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.