UK Inquiry Tracker

Toni Piel

PFD Report Partially Responded Ref: 2015-0263

Date of Report 9 July 2015

Coroner Matthew Cox

Coroner Area Manchester (North)

Response Deadline est. 3 September 2015

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

A patient was discharged home after a head injury without assessing their home circumstances or documenting discharge risk factors, violating NICE guidelines on patient observation.

View full coroner's concerns

i) At the time the deceased was discharged home following the head injury on 10 December 2014 the deceased’s home circumstances were apparently not taken into account. Had such an assessment been made it would have been noted that there was no-one able to observe the deceased at home. The NICE clinical guideline 175 issued January 2014 recommends that this should be taken into account. ii) No assessment of the risk factors in discharging the deceased was documented in the deceased’s records.

Responses

Department of Health Central Government

3 Sep 2015

Noted
The Department of Health acknowledges the concerns and Pennine Acute Hospitals NHS Trust's review, highlighting actions to improve management, supervision, assessment, and discharge of head injury patients. They note the work of Patient Safety Collaboratives, NICE guidance, and the Falls and Fragility Fracture National Audit Programme. (AI summary)

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From Ben Gummer MP Parliamentary Under Secretary of State (or Care Quality Department Richmond House of Health 79 Whitehall London SWTA ZNS POCS 947712 Tel: 020 7210 4850 Mr M Cox Assistant Coroner 0 3 SEP 2015 HM Coroner s Court The Phoenix Centre LICpl Stephen Shaw MC Heywood OLIO ILR 6 Thank you for your letter of 10h July 2015 following the inquest into the death of Toni Piel. I was very SOrry to hear of Mr Piel's death and wish to extend my sincere condolences to his family. Mr Piel died at his home address on 23rd December 2014. He had earlier fallen at home on 10lh December; suffering a head injury which resulted in an emergency admission to hospital. On that occasion his head wound had been sutured and he had been discharged home with head injury and wound care advice. Your concerns centre round the lack of adequate assessment of the risks to the patient when he was discharged home. You state that: No assessment had been made which would have uncovered that there was no-one at home to observe the patient You refer to NICE guidance issued in January 2014 which recommends home circumstances are taken into account: No assessment of risk factors around discharge was documented in the deceased records These are both operational matters for the trust involved Inote that your report has been sent to the Pennine Acute Hospitals NHS Trust. [understand that Pennine Acute has undertaken a review of this case which has resulted in actions to improve the management; supervision, assessment and discharge ofhead injury patients in their care. The Trust will provide with full details in its response. Way you

Ata national level a network of fifteen Patient Safety Collaboratives, led by Academic Health Sciences Networks, has identified improving discharge from hospital and transfers and transitions of care as a priority. The initial focus of this work is on improving communication during discharge: As the programme of work develops, it is likely that further priorities will be identified Work has also been done by the National Institute of Health and Care Excellence (NICE) to examine the issue of patients who fall in their own homes and the prevention of further falls. This has resulted in the publication of NICE's Quality Standard, 'Falls in older people: assessment after a fall and preventing further falls" in March 2015. The Falls and Fragility Fracture National Audit Programme is a national clinical audit run by the Royal College of Physicians It is designed to audit the care received by hospital patients who are vulnerable to falling or have been injured in a fall, and to facilitate quality improvement initiatives Further information on this programme can be found at: https:/Lwww rcplondon ac uklprojects falls-and-fragility-fracture-audit-programme - 2014 The NICE guideline you reference appears to be Clinical Guidance 176 on Head Injury. This recommends that patients with a head injury should only be discharged when someone is at home to supervise the patient: The section on discharge and follow-up states:
1.9.5 All patients with any degree of head injury should only be transferred to their home if it is certain that there is somebody suitable at home to supervise the patient Discharge patients with no carer at home only if suitable supervision arrangements have been organised, or when the risk of late complications is deemed negligible
1.9.6 Patients admitted after a head injury may be discharged after resolution of all significant symptoms and signs providing they have suitable supervision arrangements at home. NICE guidance is not mandatory. However,practitioners are expected to take such guidance into #ccoint: Iam grateful to you for bringing the circumstances of Mr Piel's death to my attehtion and hope that you findthis reply helpful. Hb~ BEN GUMMER fffap- fully

Sent To

Department of Health and Social Care
Pennine Acute Hospitals NHS Trust

Response Status

Linked responses 1 of 2

56-Day Deadline 3 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 12 th February 2015 Catherine McKenna, Assistant Coroner, commenced an investigation into the death of Toni Piel. The investigation was concluded at the end of the Inquest on the 26 th May 2015. The conclusion of the Inquest was that the deceased died on the 23 December 2014 at his home address, 65 Wood Park Court, Whitebank Road, Limeside, Oldham as a result of a head injury caused by a fall. The evidence did not disclose whether a head injury which occurred on 10 December 2014 and which resulted in treatment at The Royal Oldham Hospital or a separate unconnected injury caused his death, the medical cause of death being: la) Intracranial Haemorrhage lb) Head Injury lc) Fall

Circumstances of the Death

The deceased was born on 5 th March 1949 and was 65 years old at the time of his death on 23 December 2014. On the 10 th December 2014 the deceased suffered an injury to the back of his head in a fall at his home address. He was taken to the Royal Oldham Hospital by emergency ambulance. The ambulance records outline a possible recurrent fall with the fourth fall that day. The deceased stated that he had had approximately 4 cans of lager. On arrival in the emergency department it was noted that the deceased had a laceration to the back of his head approximately 5 inches, that he drank most days and that there was the possibility of recurrent falls. The injury was cleaned and closed with 4 sutures. The deceased was considered to be safe to be discharged home with head injury advice and wound care. On the 23 rd December 2014 one of the deceased’s neighbours contacted the police as he was unable to make contact with the deceased. Entry to the deceased’s flat was forced and the deceased’s body was found lying on the floor by the bed fully clothed. A Post Mortem Examination was conducted by Consultant Histopathologist. He noted a large subdural haematoma in the middle and posterior regions of the brain and a prominent subarachnoid haemorrhage in both temporal lobes and cerebellum. He said the evidence was consistent with another injury suffered at The Royal Oldham Hospital 10 December 2014. In his opinion the possible explanations were that the fall which resulted in treatment at The Royal Oldham Hospital on 10 December 2014 had triggered a further fall which had led to his death or that he had suffered a fall which was not connected with the fall for which treatment was provided on 10 December 2014.