Irshad Ali
PFD Report
All Responded
Ref: 2014-0387
All 1 response received
· Deadline: 24 Oct 2014
Coroner's Concerns (AI summary)
The report identifies missing records of required nursing observations, a failure to complete neurological observations before discharge as stipulated, and miscommunication regarding physiotherapy assessment before discharge.
View full coroner's concerns
1. The nursing staff should have checked on Mr Ali every two hours through the night, but there was no record of intentional rounding on 24/25 March. There was a record of the night before and a record of the night after, but not the night that Mr Ali fell. The chart appears to have gone missing.
2. Though the senior sister looking after Mr Ali on the morning of 25 March assured me that neurological observations were carried out hourly after his fall, there was no record of this. Again, the chart appears to have gone missing.
3. The consultant in charge of Mr Ali’s care stipulated that his junior medical colleagues should perform neurological observations before Mr Ali could be discharged, yet this did not take place.
The sister in charge told me that she asked the registrar if Mr Ali was neurologically stable enough to be discharged, and she said yes.
4. The consultant in charge of Mr Ali’s care also stipulated that Mr Ali should undergo physiotherapy assessment before he could be discharged, yet this did not take place.
The sister in charge told me that she knew about this and she knew that a physiotherapist was going to review Mr Ali that afternoon. However, she did not pass this information on to the nurse who looked after Mr Ali during the sister’s lunch break, nor to Mr Ali’s family. The nurse said that she did tell Mr Ali’s family he was not ready for discharge, but she gave them the discharge paperwork before she went for lunch and so they assumed he could go.
Both the doctor and the nurse who gave evidence told me that they now think that discharge packs should not be given out until the patient’s discharge is complete.
5. Both the doctor and the nurse thought that it would be helpful to have a nurse accompany the doctors on their ward rounds.
2. Though the senior sister looking after Mr Ali on the morning of 25 March assured me that neurological observations were carried out hourly after his fall, there was no record of this. Again, the chart appears to have gone missing.
3. The consultant in charge of Mr Ali’s care stipulated that his junior medical colleagues should perform neurological observations before Mr Ali could be discharged, yet this did not take place.
The sister in charge told me that she asked the registrar if Mr Ali was neurologically stable enough to be discharged, and she said yes.
4. The consultant in charge of Mr Ali’s care also stipulated that Mr Ali should undergo physiotherapy assessment before he could be discharged, yet this did not take place.
The sister in charge told me that she knew about this and she knew that a physiotherapist was going to review Mr Ali that afternoon. However, she did not pass this information on to the nurse who looked after Mr Ali during the sister’s lunch break, nor to Mr Ali’s family. The nurse said that she did tell Mr Ali’s family he was not ready for discharge, but she gave them the discharge paperwork before she went for lunch and so they assumed he could go.
Both the doctor and the nurse who gave evidence told me that they now think that discharge packs should not be given out until the patient’s discharge is complete.
5. Both the doctor and the nurse thought that it would be helpful to have a nurse accompany the doctors on their ward rounds.
Responses
Action Taken
The Trust has taken multiple actions including monthly nursing audits of patient note filing, reminders to nurses about discharge policies, and a review of processes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team, and the Senior Sister will be given a copy of the consultants' rota to facilitate nursing presence on ward rounds. (AI summary)
The Trust has taken multiple actions including monthly nursing audits of patient note filing, reminders to nurses about discharge policies, and a review of processes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team, and the Senior Sister will be given a copy of the consultants' rota to facilitate nursing presence on ward rounds. (AI summary)
View full response
Dear Coroner Hassell Inquest Touching the Death of Irshad Ali write in response to your Regulation 28: Report to Prevent Future Deaths, dated 29 August 2014_ The investigation into your concerns regarding the lack of documentation recording intentional rounding on the night of 24/25 March 2014, the missing chart recording neurological observations carried out after his fall; the lack of documentation of the neurological examination carried out by the consultant's junior colleagues, the lack of a physiotherapy assessment to discharge, that this was not communicated by the nurse-in-charge to her colleague and to the family, the provision of the discharge pack to the family when he was not ready to be discharged, and the evidence that a nurse accompanying the doctors on their ward rounds would be helpful, has now been concluded. am satisfied that this investigation has been sufficiently robust; in that we have scrutinised all relevant records and interviewed staff to inform our investigation. write to apprise you of the conclusions of the investigation: During the investigation, senior qualified nursing staff contacted the nurse allocated to care for Mr Ali on the night of 24/15 March 2014, who confirmed that the intentional rounding did take place: The intentional rounding chart for this night remains missing: Evidence has been adduced that this is because the medical notes had been filed incorrectly: This will be dealt with by a monthly senior nursing audit of the integrity of the filing of patients' notes and spot checks for intentional rounding compliance and correct filing of medical notes: The missing neurological observation chart has been located and it confirms that appropriate neurological observations were carried out after Mr Ali's fall. This chart had been inadvertently misfiled. Senior medical staff have confirmed that the induction for new medical trainees now includes a section on documentation and management of falls, emaphasising the requirement to document actions in the medical records. To ensure that all future referrals (including physiotherapy referrals) made for patients are signed and dated in the medical notes when actioned, staff have been reminded of the importance of thorough clinical handover This will be further highlighted during a twice daily staff safety briefing, and followed up by spot checks of patient notes to check that verbal referrals are being documented as actioned. prior yet
Barts Health NNHS] NHS Trust To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes Training for nurses in neurological observations, is being provided by the Critical Care Outreach Team: Effectiveness will be measured by audit of nurses' understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations_ It is policy that the copy of the patients' discharge letter should be given once all facets of the discharge process are complete. Nurses have been reminded of the policy and the requirement to update the patient information sheet with the information that the discharge summary should be given to the patient alongside their discharge medications To facilitate this, the Trust continues to cultivate a continued effective relationship with the Trust discharge lounge_ Ward 14F currently has five specialties, all of which our doctors ward rounds. To enable a nursing presence on each of the ward rounds; the senior sister will be given a copy of the consultants rota and proposed time of ward rounds, and agreement has been reached that the doctors will not leave the ward until have verbally communicated the proposed plan of care for their patients to the Nurse in charge of the ward, or responsible for that group of patients. This will be reviewed daily with the feedback provided by the consultants, with a weekly combined nursing and medical review: We have taken this as an opportunity to review our processes to enhance future care. The outcome of the investigation will be shared with all Trust medical and nursing staff; to ensure that staff involved implement the above changes and audit the adequacy and effectiveness of the changes_ Thank you for bringing your concerns to my attention: trust that you are assured have taken them seriously and investigated them appropriately.
Barts Health NNHS] NHS Trust To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes Training for nurses in neurological observations, is being provided by the Critical Care Outreach Team: Effectiveness will be measured by audit of nurses' understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations_ It is policy that the copy of the patients' discharge letter should be given once all facets of the discharge process are complete. Nurses have been reminded of the policy and the requirement to update the patient information sheet with the information that the discharge summary should be given to the patient alongside their discharge medications To facilitate this, the Trust continues to cultivate a continued effective relationship with the Trust discharge lounge_ Ward 14F currently has five specialties, all of which our doctors ward rounds. To enable a nursing presence on each of the ward rounds; the senior sister will be given a copy of the consultants rota and proposed time of ward rounds, and agreement has been reached that the doctors will not leave the ward until have verbally communicated the proposed plan of care for their patients to the Nurse in charge of the ward, or responsible for that group of patients. This will be reviewed daily with the feedback provided by the consultants, with a weekly combined nursing and medical review: We have taken this as an opportunity to review our processes to enhance future care. The outcome of the investigation will be shared with all Trust medical and nursing staff; to ensure that staff involved implement the above changes and audit the adequacy and effectiveness of the changes_ Thank you for bringing your concerns to my attention: trust that you are assured have taken them seriously and investigated them appropriately.
Sent To
- Barts Health
Response Status
Linked responses
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56-Day Deadline
24 Oct 2014
All responses received
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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 8 May 2014, I commenced an investigation into the death of Irshad Ali, aged 79 years. The investigation concluded at the end of the inquest on 27 August 2014.
I made a determination at inquest that death was caused by an accident, when Mr Ali fell in the Royal London Hospital in the early hours of 25 March 2014 and hit his head, at the time suffering severe liver cirrhosis.
His medical cause of death was:
1a bronchopneumonia 1b traumatic intracranial haemorrhage 2 end stage non alcoholic steatohepatitis cirrhosis
I made a determination at inquest that death was caused by an accident, when Mr Ali fell in the Royal London Hospital in the early hours of 25 March 2014 and hit his head, at the time suffering severe liver cirrhosis.
His medical cause of death was:
1a bronchopneumonia 1b traumatic intracranial haemorrhage 2 end stage non alcoholic steatohepatitis cirrhosis
Circumstances of the Death
Mr Ali was admitted to hospital on for drainage of ascites. He was found on the floor of the ward at 4am on the morning of 25 March, having apparently sustained an unwitnessed fall. He left the hospital at lunch time, under the impression that he had been discharged. He later re-presented to the emergency unit, and was diagnosed with a massive head injury. In view of his end stage liver disease, surgery was not advised. He died six weeks later of a consequent chest infection.
Copies Sent To
children of Irshad Ali
Royal London Hospital
Royal London Hospital
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.