Agnes Hannan
PFD Report
All Responded
Ref: 2014-0573
All 1 response received
· Deadline: 22 Dec 2014
Coroner's Concerns (AI summary)
Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of consultant oversight. Delays in CT scanning and end-of-life discussions were also noted.
View full coroner's concerns
_ There was an actual, or perceived; lack of availability of the hospital notes and records of previous diagnoses and treatments by_hospital doctors, for To: Mary the bility, the staff working in the Emergency Department On one occasion whilst she was an in-patient; Mrs Hannan who was desperately ill and needing intra-venous hydration; was found to be lying in a soaking wet bed because the tube leading to her cannula had become dislodged and disconnected: The nursing staff had failed to notice this problem: The doctors in evidence, acknowledged that her lack of hydration would inevitably have worsened her already thrombosed veins. There was extremely poor communication between hospital staff and the patient (and her family), and between and amongst themselves. There was evidence of a lack of handover between staff; and this was exacerbated by the fact that the medical and nursing notes were frequently inadequate. Whilst it was, or should have been apparent that she was already under the long term care ofl no-one made any attempt to speak with him or his department for advice. Throughout the hospital notes for this patient; there is widespread use of initials and abbreviations On at least one occasion in court; none of the medicallnursing staff present could explain to me what the abbreviation in the notes meant: This patient needed very careful monitoring at all times and there was period of 24 hours when no nursing observations were carried out or recorded: The communication of Medicallnursing diagnoses and decisions to the family, was extremely poor and frequently did not happen. An example of this was the failure by the staff to explain the critical nature of Mrs Hannan'$ condition, so that the grandson of the deceased failed to be able to come and see his grandmother in hospital before she died. was told that there is no CT scanner facility available for the use of the ED out of normal hours. This meant that a scan was delayedlmissed and led to a in diagnosis of her underlying condition: was told in evidence that it takes up to three months for the paper records of the ED to be scanned electronically. This means that recent notes may not be available on the computer screens for the staff in the ED
10. When a patient is admitted there is little or no logic as to determining which Consiltant challhe in charge: In this case she was allocated under the care ofl who was not even in the hospital for the first two days of her admission and in fact who NEVER actually saw the patient:
11. The End-of Life Care Pathway must be initiated only after full and meaningful discussion with the patient andlor her family. In the present case there was no evidence to show that any such discussion had taken place
10. When a patient is admitted there is little or no logic as to determining which Consiltant challhe in charge: In this case she was allocated under the care ofl who was not even in the hospital for the first two days of her admission and in fact who NEVER actually saw the patient:
11. The End-of Life Care Pathway must be initiated only after full and meaningful discussion with the patient andlor her family. In the present case there was no evidence to show that any such discussion had taken place
Responses
Action Taken
The hospital replaced its computer system for medical records, is purchasing a scanner for the A&E department to improve record accessibility, and has reviewed and updated its DNACPR policy, emphasizing discussions with patients and families; this includes a DVD available on the intranet and promoted via screensavers. (AI summary)
The hospital replaced its computer system for medical records, is purchasing a scanner for the A&E department to improve record accessibility, and has reviewed and updated its DNACPR policy, emphasizing discussions with patients and families; this includes a DVD available on the intranet and promoted via screensavers. (AI summary)
View full response
Dear Mr Pollard gnes Hannan (Deceasod) VOunkyoutifor your letter dated 27" October 2014 enclosing a Regulation 28 your investigation into death of Agnes Hannan report following am sorry to note that the evidence raised a number of concerns. below will provide You with reassurance of the steps that have been that the responses improve patient and minimise the risk of future deaths taken by the Trust to individually (adopting your numbering): Addressing your concerns That there was an actual, or perceived, lack of availability of the and records of previous diagnoses and treatments hospital notes staff working in the Emergency by hospital doctors, for the Department: Response atencomputer system for medical records which was in place at the time of Mrs attetedances at the Accident & Emergency Department has since been Hannan's system. Staff working in Accident & Emergency are able to replaced by a new patients' medical records including access extensive details of including aeencaneeoridsAccideig cErreerpendence, previous in and out-patient attendances Emergency: Witeiphieicerrecords of all patients seen in the Accident & Emergency within the department for ease of access for a period Of five Department are held attendance so that areasesolacccessible:foeriad atterdingeon polensgwhoarhtse to the department within that period. After five on patients who might return computer weeks the notes are scanned on to the system: In order to minimise delay in those notes accessible the Trust is purchasing a scanner specifically for the Accidentel on the system Emergency Department and Everyone Matters RECEIVED 2014 DEC the Mary hope safety they being
once in place staff 'training will be arranged to ensure that the scanning and uploading process is carried out efficiently. On one occasion whilst she was an in-patient; Mrs Hannan who was desperately ill and needing intravenous hydration, was found to be lying in a soaking wet bed because the tube to her cannula had become dislodged and disconnected. The nursing staff had failed to notice this problem: The doctors in evidence, acknowledged that her Iack of hydration would inevitably have worsened her already thrombosed veins. Response The Trusts nursing staff are trained to carefully insert and tape cannulas to the skin to minimise the risk of them becoming loose, disconnected or out: Unfortunately, despite taping them down cannulas do, on occasions, become loose; for example, if patients inadvertently dislodge them Ifa cannula becomes dislodged patients may alert reursing staff so that it can be re-secured to prevent the loss of fluid. We appreciate that on occasions patients are not aware or are not well enough to alert nursing staff themselves. If that occurs our staff should become aware that there is a detached cannula andlor loss of fluid on next attending at the patient's bedside. Whilst the risk of cannulas detaching cannot unfortunately be completely avoided we have taken steps to minimise that risk by training our nursing staff to carefully insert and tape cannulas and to be observant and check for problems when attending on patients There was extremely poor communication between hospital staff and patient (and her family), and between and amongst themselves: There was evidence of a lack of handover between staff, and this was exacerbated by the fact that the medical and nursing notes were frequently inadequate. Response The Trust promotes safe handover of patient care by providing protected time; to enable handover of all relevant patient information, both at the beginning and end of shifts . The Trust is currently undertaking a review of its current training on record keeping standards which will include an emphasis on the importance of good communication between staff and the importance of careful handover. Whilst itWaSoshould have been apparent that she was under the long-term care of no-one made any attempt to speak with him or his departmentfor advice. Response The Trusts medical staff treating Mrs Hannan had access to details of her previous medical history including her care under_ and therefore should have been aware previous involvement in her treatment The records available to the clinical staff_ dlid provide the means by which could obtain information about it and contact or other members of his department whenever needed to. Professional staff have been reminded of the importance of both reviewing the patients notes (either the physical notes or electronically on the Lorenzo system) and communicating with the previous relevant leading falling the they they
consultant and or their department if advice is required in order to ensure the patient receives appropriate treatment Throughout the hospital notes for this patient; there is widespread use of initials and abbreviations. On at least one occasion in court, none of the medical nursing staff present could explain to me what the abbreviation in notes meant: Response As mentioned above the Trust is undertaking a review of its current on record keeping standards The training will reinforce the need for clarity and the importance of avoiding use of unclear abbreviations This patient needed very careful monitoring at all times and yet there was a period of 24 hours when no nursing observations were carried out or recorded. Response Atthe time of Mrs Hannan's treatment the Trust used a PARS scoring system for recording nursing observations: That system is designed to track observations, determine the regularity of them and trigger escalation of care whenever required. Instructions for use of the PARS score system was provided to nurses through training and also by clear explanatory notes within each individual nursing observation chart: The insufficient observations in this case arise from failure to adhere to the Trust's PARS system: Since Mrs Hannan's treatment the PARS scoring system has been replaced by a different system called the NEWS system and all of the Trusts staff have been trained in the use of it A quick reference NEWS escalation and response guide has also been made available to all staff. The NEWS system is more sensitive than most other existing systems and it provides an enhanced level of surveillance and clinical review of patients with greater specificity in identifying those at risk of clinical deterioration. The communication of medical nursing diagnoses and decisions to the family, was extremely poor and frequently did not happen: An example of this was the failure by the staff to explain the critical nature of Mrs Hannan's condition, so that the grandson of the deceased failed to be able to come and see his grandmother in hospital before she died:. Response The Trust is striving to improve communication between staff and family members_ The Trust has created a bedside booklet available for patients and relatives 'Patient Safety Keeping you safe during your stay in hospital"_ This includes a section on recognising acute illness and how this is monitored and empowers patients and their families to ask questions. Professional staff have been reminded of their duties to communicate proactively and effectively. the training the
was told that there is no CT scanner facility available for of normal hours. This meant that a scan use of the ED out in diagnosis of her underlying was delayed missed and led to a condition. Response This is incorrect; there was in September 2013,as there still is, a CT use of the Emergency Deparimentebotl in and Out Oierorstia/ hourG, socaateoalailable for the scan to be delayed or missed or lead to so that could not cause a arrangement for this in diagnosis_ Please be reassured that the Service pre-dates 2002. There was also the facility to report the acquired bur outsourced reporting company Radiology Reporting Onlinec images apologise that this was not clearly conveyed the Trust witnesses' can only evidence. was told in evidence that it takes Up to three months for the the ED to be scanned electronically. This paper records of available on the means that recent notes may not be computer screens for the staff in the ED. Response Anew scanner has been purchased specifically for the Accident and to minimise any in records accessible on the computer system. department any in records being uploaded on to the system. Staff training That will avoid scheduled to ensure that the scanning and uploading has already been process is carried out efficiently: 10 When & patient is admitted there is little or no logic as to Consultant shall be in charge. In this case she was allocated determining which who was not even in the hospital for the first under the care of admission and in fact who never actually saw the patient: of her Response roleiserfor iany confusion at inquest and if the patients family were not informed arrangements in place for the medical care of Mrs Hannan. of the was in the hospital when Hannan understand that At the time, wwas transferred from MAU to Ward 31, Adult Medicine_ was on-call for energencies ad was with other patients in department: who is Registrar was asked to ndertake another examination of Mrs Hannan and as supervising consultans; clinical over the telephone be assured that whilst on the Iprovided advice daily basis by other well qualified doctors_ The ward; Irs Hannan was seen on a consultants will be fed back to all division: concerns regarding the direct contact of 11 Tise Endcof-Life Care Pathway must be initiated only after full and discussion with patient and or her In the present meaningful no evidence to show that any such discussion had teker case there was place. Response the delay delay using during Emergency delay being delay two days Mrs Please the family.
Trust's DNACPR policy been reviewed since Mrs Hannan was treated at the Trust and in accordance with R (on the application of Hospitals NHS Foundation Trust The new policy emphasizes Cambridge University with patients their family. a DVD has been created the importance of discussion intranet This was also promoted" and is available on the Trust's through screensavers to inform staff of the new policy and emphasize its importance_ The current Trust policy with decisions relating to DNACPR, which November 2014, stresses the importance of clear accurate was updated in the patient and those close to the patient (unless and honest communication with including provision of information the patient has requested confidentiality) explained. and checking their understanding of what has been do that have addressed your concerns and that have reassured taken by the Trust will prevent the recurrence of similar you that the steps case of Mrs Hannan. set of circumstances as those in the Should you have any further questions arising the contents of this letter hesitate to contact me_ am again sorry that your investigation into this please do not such significant concern to issue a Regulation 28 Report but death caused you reassured. hope that you are now
once in place staff 'training will be arranged to ensure that the scanning and uploading process is carried out efficiently. On one occasion whilst she was an in-patient; Mrs Hannan who was desperately ill and needing intravenous hydration, was found to be lying in a soaking wet bed because the tube to her cannula had become dislodged and disconnected. The nursing staff had failed to notice this problem: The doctors in evidence, acknowledged that her Iack of hydration would inevitably have worsened her already thrombosed veins. Response The Trusts nursing staff are trained to carefully insert and tape cannulas to the skin to minimise the risk of them becoming loose, disconnected or out: Unfortunately, despite taping them down cannulas do, on occasions, become loose; for example, if patients inadvertently dislodge them Ifa cannula becomes dislodged patients may alert reursing staff so that it can be re-secured to prevent the loss of fluid. We appreciate that on occasions patients are not aware or are not well enough to alert nursing staff themselves. If that occurs our staff should become aware that there is a detached cannula andlor loss of fluid on next attending at the patient's bedside. Whilst the risk of cannulas detaching cannot unfortunately be completely avoided we have taken steps to minimise that risk by training our nursing staff to carefully insert and tape cannulas and to be observant and check for problems when attending on patients There was extremely poor communication between hospital staff and patient (and her family), and between and amongst themselves: There was evidence of a lack of handover between staff, and this was exacerbated by the fact that the medical and nursing notes were frequently inadequate. Response The Trust promotes safe handover of patient care by providing protected time; to enable handover of all relevant patient information, both at the beginning and end of shifts . The Trust is currently undertaking a review of its current training on record keeping standards which will include an emphasis on the importance of good communication between staff and the importance of careful handover. Whilst itWaSoshould have been apparent that she was under the long-term care of no-one made any attempt to speak with him or his departmentfor advice. Response The Trusts medical staff treating Mrs Hannan had access to details of her previous medical history including her care under_ and therefore should have been aware previous involvement in her treatment The records available to the clinical staff_ dlid provide the means by which could obtain information about it and contact or other members of his department whenever needed to. Professional staff have been reminded of the importance of both reviewing the patients notes (either the physical notes or electronically on the Lorenzo system) and communicating with the previous relevant leading falling the they they
consultant and or their department if advice is required in order to ensure the patient receives appropriate treatment Throughout the hospital notes for this patient; there is widespread use of initials and abbreviations. On at least one occasion in court, none of the medical nursing staff present could explain to me what the abbreviation in notes meant: Response As mentioned above the Trust is undertaking a review of its current on record keeping standards The training will reinforce the need for clarity and the importance of avoiding use of unclear abbreviations This patient needed very careful monitoring at all times and yet there was a period of 24 hours when no nursing observations were carried out or recorded. Response Atthe time of Mrs Hannan's treatment the Trust used a PARS scoring system for recording nursing observations: That system is designed to track observations, determine the regularity of them and trigger escalation of care whenever required. Instructions for use of the PARS score system was provided to nurses through training and also by clear explanatory notes within each individual nursing observation chart: The insufficient observations in this case arise from failure to adhere to the Trust's PARS system: Since Mrs Hannan's treatment the PARS scoring system has been replaced by a different system called the NEWS system and all of the Trusts staff have been trained in the use of it A quick reference NEWS escalation and response guide has also been made available to all staff. The NEWS system is more sensitive than most other existing systems and it provides an enhanced level of surveillance and clinical review of patients with greater specificity in identifying those at risk of clinical deterioration. The communication of medical nursing diagnoses and decisions to the family, was extremely poor and frequently did not happen: An example of this was the failure by the staff to explain the critical nature of Mrs Hannan's condition, so that the grandson of the deceased failed to be able to come and see his grandmother in hospital before she died:. Response The Trust is striving to improve communication between staff and family members_ The Trust has created a bedside booklet available for patients and relatives 'Patient Safety Keeping you safe during your stay in hospital"_ This includes a section on recognising acute illness and how this is monitored and empowers patients and their families to ask questions. Professional staff have been reminded of their duties to communicate proactively and effectively. the training the
was told that there is no CT scanner facility available for of normal hours. This meant that a scan use of the ED out in diagnosis of her underlying was delayed missed and led to a condition. Response This is incorrect; there was in September 2013,as there still is, a CT use of the Emergency Deparimentebotl in and Out Oierorstia/ hourG, socaateoalailable for the scan to be delayed or missed or lead to so that could not cause a arrangement for this in diagnosis_ Please be reassured that the Service pre-dates 2002. There was also the facility to report the acquired bur outsourced reporting company Radiology Reporting Onlinec images apologise that this was not clearly conveyed the Trust witnesses' can only evidence. was told in evidence that it takes Up to three months for the the ED to be scanned electronically. This paper records of available on the means that recent notes may not be computer screens for the staff in the ED. Response Anew scanner has been purchased specifically for the Accident and to minimise any in records accessible on the computer system. department any in records being uploaded on to the system. Staff training That will avoid scheduled to ensure that the scanning and uploading has already been process is carried out efficiently: 10 When & patient is admitted there is little or no logic as to Consultant shall be in charge. In this case she was allocated determining which who was not even in the hospital for the first under the care of admission and in fact who never actually saw the patient: of her Response roleiserfor iany confusion at inquest and if the patients family were not informed arrangements in place for the medical care of Mrs Hannan. of the was in the hospital when Hannan understand that At the time, wwas transferred from MAU to Ward 31, Adult Medicine_ was on-call for energencies ad was with other patients in department: who is Registrar was asked to ndertake another examination of Mrs Hannan and as supervising consultans; clinical over the telephone be assured that whilst on the Iprovided advice daily basis by other well qualified doctors_ The ward; Irs Hannan was seen on a consultants will be fed back to all division: concerns regarding the direct contact of 11 Tise Endcof-Life Care Pathway must be initiated only after full and discussion with patient and or her In the present meaningful no evidence to show that any such discussion had teker case there was place. Response the delay delay using during Emergency delay being delay two days Mrs Please the family.
Trust's DNACPR policy been reviewed since Mrs Hannan was treated at the Trust and in accordance with R (on the application of Hospitals NHS Foundation Trust The new policy emphasizes Cambridge University with patients their family. a DVD has been created the importance of discussion intranet This was also promoted" and is available on the Trust's through screensavers to inform staff of the new policy and emphasize its importance_ The current Trust policy with decisions relating to DNACPR, which November 2014, stresses the importance of clear accurate was updated in the patient and those close to the patient (unless and honest communication with including provision of information the patient has requested confidentiality) explained. and checking their understanding of what has been do that have addressed your concerns and that have reassured taken by the Trust will prevent the recurrence of similar you that the steps case of Mrs Hannan. set of circumstances as those in the Should you have any further questions arising the contents of this letter hesitate to contact me_ am again sorry that your investigation into this please do not such significant concern to issue a Regulation 28 Report but death caused you reassured. hope that you are now
Sent To
- Tameside Hospital NHS Foundation Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
22 Dec 2014
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 2nd October 2013 commenced an investigation into the death of Agnes Hannan dob 6th December 1937 The investigation concluded on 23r October 2014 and the conclusion was one of Natural Causes. The medical cause of death was 1a Bowel Infarction 1b Superior Mesenteric Vein Thrombosis 1c Hepatic cirrhosis due to auto immune hepatitis_
Circumstances of the Death
Mrs Agnes Hannan was a 75 year old lady who had been diagnosed with Auto Immune Hepatitis, with cirrhosis, in June 2013. On the 16th, 17th and 18th September 2013 she presented to the ED of Tameside General Hospital. On each occasion she reported severe abdominal pains_ On the third attendance she was finally admitted to the hospital. Over the next few days, whilst it transpires that her death was, on the balance of probabilities an inevita opportunities were missed to make an earlier diagnosis of her condition, to alleviate her symptoms and to inform her family members as to her condition. She was, allegedly, placed on the Liverpool Care Pathway, although no clear indication of this appears in her clinical notes nor was any clear indication given to her family: She was declared not for active resuscitation without any, or any adequate, discussion with her family members: During her visits to the ED and perhaps even more pertinently whilst an in-patient at the hospital, there seems to have been an almost complete failure to obtain details of her already existing Consultant care and to conduct multi-disciplinary decision making processes On the 20th September she was finally diagnosed as suffering from Superior Mesenteric Vein Thrombosis which caused an infarction of her bowel; leading to her death on the 21st September
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.