Jayne Jowett
PFD Report
Partially Responded
Ref: 2015-0175
Coroner's Concerns (AI summary)
PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical clinical signs. There's no clear protocol for GP collaboration or for communicating patient physical conditions to GPs.
View full coroner's concerns
_ _ PIC Staff Training in National Early Warning Scores: Training in both interpretation of scores, and response to escalation in scores has not to date demonstrated improvement in assessment of a patients clinical The the days and using condition: The impact 0f training on patient assessment requires ongoing audit and monitoring PIC staff at Annesley House have low levels of understanding of the significance of clinical signs such as cyanosis, pallor; breathlessness, and the significance of a patient needing oxygen treatment There are no plans currently in place to address this There remains no clear current service level agreement regarding how best for PIC to work with the local GP surgery to provide high quality joint care There is no clear guidance that ensures all information regarding a patient's physical condition is communicated to a GP when seeing a patient.
Responses
Action Taken
All qualified staff at relevant sites have been retrained on NEWS following the inquest, and this will form part of the induction training. Annesley House has a service level agreement with the local GP practice. (AI summary)
All qualified staff at relevant sites have been retrained on NEWS following the inquest, and this will form part of the induction training. Annesley House has a service level agreement with the local GP practice. (AI summary)
View full response
Dear Dr Didcock Inguest into the death o Jayne Jowett Resnonse to 4 Regulation 28 Repor ] write in response to your Regulation 28 Report dated Is 2015, am grateful to you for bringing these matters to my attention as Partnerships in Care ("PIC ) lake all patient safety issues very seriously, particularly where there may be lessons to be learnt morc widely: Thank you also for the extension of time that you kindly granted to enabie us to respond fully The death of Jowett was obviously an extremely sad event and my sympathy goes to everyone who knew her: From the perspective of PIC, if there are lessons to be learnt; we will ensure that these are appropriately addressed_ Your Report of ]st raises thrcc issues pursuant to Rcgulation 28 t0 which ] will respond in tum_ PIC Staff Training in National Early Warning Scores ("NEWS"): Training in both interpretation of Scores and response to Escalaticn in Scores has not to datc demonstrated improvement in assessment of & patient's clinical condition. The impact of training on paticnt assessment requires ongoing audit and monitoring; All nursing staff at rclevant sites were trained on the NEWS when this was rolled out originally in 2013, and all qualified staff at those sites have been retrained on this following this inquest. We have now also arranged for this to form part of the induction training so that all new qualified staff will be trained on this as part of their induction to PIC. Additionally, the training is to be refreshed annually. Staff receive an email reminder of the need 10 do this annual refresher training: Part of the PIC internal audit system includes checking that staff complete their necessary training; Further; the policy and details relating t0 NEWS are available for staff t0 access on the PIC intranet s0 that they can refresh themselves at any time where necessary. INVESTORS IN PEOPLE Bronze Partnerships in Cere Limited i6 registered in England, n10, 02622784 Our va ues- Registered 0ii44s80? Inperial Plece Maxwel Road, Eorehanwood, Valuing poople Cering safely Integrily Herttordshire; WDS {JN Working together Quality May ` Jayne May
PIC has reviewed its medical emergencies policy with the assistance of the Group Medical Director and we have placed a physical hcalth NEWS algorithm in each clinic room and ward office at Annesiey House. Overview monitoring of the use of NEWS is undertaken by OuT registered managers aS part of their general duties and through corporate clinical govcrnance mcetings, which are held monthly. Direct monitoring is undertaken by physical health care issues slanding agenda ilem in the moming management meeting at Annesley hospital and anybody who has had any physical health concerns requiring the NEWS to be used will be discussed at that meeting: The successful use of NEWS is evidenced by the fact that patienls have been referred ta the GP or A & Eas & result of the use of this. PIC Staff at Annesley House have low levels of understanding of the significancc of clinical signs such as cyanosis, pallor; brcathlessncss, and thc significancc of & patient nceding oxygen trcatment, There are nO plans currently in place to address this: The training provided by PIC is extensive This includcs training in Intermediate Life Support (ILS") for all doctors, registered nurses, and tutors responsible for training staff in relation to the management of violence and aggression. The ILS training that we provide includes recognition of these issues The training providers who deliver this are all externally accredited to provide on these matters, and the content of the courses is periodically reviewed by PIC &8 part of its governance processes. We will also be cnsuring that Staff arc aware of the specific identification of clinical issues that you have raiscd here through the one to One supervisions in which staff have their clinical practice discussed by a Senior Manager. There remains no clear current Service Level Agreement regarding how best for PIC to work with the local GP Surgery to provide high quality joint care There is no clcar guidance that ensures all information regarding the patient's physical condition is com municated to a GP when patient: Annesley House works closely with the local GP practice at Ashfield House Surgery- am pleased t0 say that we have a Service Level Agreement in place and a cOpy of this is attached_ In your Regulation 28 Report, You indicaled that you would find it helpful for both PIC and the GP practice to consider a joint response. am pleased to say that Annesley House has a working relationship with Ashfield House which believe can only be to the benefit of our residents and will further assist in addressing the issues raised at paragraph 3 above The efficacy of that working relationship is evidenced by the fact that this response is indeed sent to You &5 & joint response both on behalf of PIC and Ashfield The content of this letter has been expressly approved by [ t0 whom your Report was sent on behalf of Partnerships in Care Wtots belle: contee tpgcinet being training training seeing good Surgery, House Surgery.
the surgcry: have signed this letter on behalf of both Respondents which ] (rust is acceptable_ In conclusion; am grateful to you for bringing these matters (0 my atlention and ] hope this lettcr provides uscfuul information aS to how these issules are addressed_
PIC has reviewed its medical emergencies policy with the assistance of the Group Medical Director and we have placed a physical hcalth NEWS algorithm in each clinic room and ward office at Annesiey House. Overview monitoring of the use of NEWS is undertaken by OuT registered managers aS part of their general duties and through corporate clinical govcrnance mcetings, which are held monthly. Direct monitoring is undertaken by physical health care issues slanding agenda ilem in the moming management meeting at Annesley hospital and anybody who has had any physical health concerns requiring the NEWS to be used will be discussed at that meeting: The successful use of NEWS is evidenced by the fact that patienls have been referred ta the GP or A & Eas & result of the use of this. PIC Staff at Annesley House have low levels of understanding of the significancc of clinical signs such as cyanosis, pallor; brcathlessncss, and thc significancc of & patient nceding oxygen trcatment, There are nO plans currently in place to address this: The training provided by PIC is extensive This includcs training in Intermediate Life Support (ILS") for all doctors, registered nurses, and tutors responsible for training staff in relation to the management of violence and aggression. The ILS training that we provide includes recognition of these issues The training providers who deliver this are all externally accredited to provide on these matters, and the content of the courses is periodically reviewed by PIC &8 part of its governance processes. We will also be cnsuring that Staff arc aware of the specific identification of clinical issues that you have raiscd here through the one to One supervisions in which staff have their clinical practice discussed by a Senior Manager. There remains no clear current Service Level Agreement regarding how best for PIC to work with the local GP Surgery to provide high quality joint care There is no clcar guidance that ensures all information regarding the patient's physical condition is com municated to a GP when patient: Annesley House works closely with the local GP practice at Ashfield House Surgery- am pleased t0 say that we have a Service Level Agreement in place and a cOpy of this is attached_ In your Regulation 28 Report, You indicaled that you would find it helpful for both PIC and the GP practice to consider a joint response. am pleased to say that Annesley House has a working relationship with Ashfield House which believe can only be to the benefit of our residents and will further assist in addressing the issues raised at paragraph 3 above The efficacy of that working relationship is evidenced by the fact that this response is indeed sent to You &5 & joint response both on behalf of PIC and Ashfield The content of this letter has been expressly approved by [ t0 whom your Report was sent on behalf of Partnerships in Care Wtots belle: contee tpgcinet being training training seeing good Surgery, House Surgery.
the surgcry: have signed this letter on behalf of both Respondents which ] (rust is acceptable_ In conclusion; am grateful to you for bringing these matters (0 my atlention and ] hope this lettcr provides uscfuul information aS to how these issules are addressed_
Sent To
- Partnerships In Care
Response Status
Linked responses
1 of 2
56-Day Deadline
26 Jun 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 29th October 2014, commenced an investigation into the death of Jayne Jowett, aged 30 years. The investigation concluded at the end of the inquest on 27th March 2015_ conclusion of the inquest was a Narrative as follows: On 15th September 2014 Ms Jayne Jowett became unwell She had intermittent but continuing respiratory difficulties, with low oxygen saturations at times in the prior to her death. She was not taken to hospital for assessment: She died of a pulmonary embolus on the 23rd September 2014.
Circumstances of the Death
Ms Jowett was resident at Annesley House, a Partnerships in Care facility, providing low secure locked rehabilitation mental health care for women. She was detained under section 47/49 of the Mental Health Act 1983. She had a learning disability and a personality disorder: She was on a range of psychotropic medication, and had asthma_ She was smoker From the 15"h September 2014 she was unwell with intermittent symptoms of dizziness, breathlessness and episodes of collapse, needing oxygen. She was seen by the doctors and nurses at Annesley House, and by her GP. Her vital signs were monitored the National Early Warning Score (NEWS) system. Guidelines as to how to respond to rising NEWS were not followed, and no hospital assessment was organised. There were missed opportunities by both Partnerships in Care and by the GP to recognise and respond to her clinical condition in the days prior to her death Following the Hearing received an additional statement and documents from Partnerships in Care addressing issues that arose during evidence. These documents went some way to addressing concerns raised;, however, in my view there remain outstanding concerns that allow for the continuation of circumstances creating a risk that other deaths will occur if such matters are not addressed_
Inquest Conclusion
On 15th September 2014 Ms Jayne Jowett became unwell She had intermittent but continuing respiratory difficulties, with low oxygen saturations at times in the prior to her death. She was not taken to hospital for assessment: She died of a pulmonary embolus on the 23rd September 2014.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.