Robert Perkins
PFD Report
All Responded
Ref: 2014-0195
All 1 response received
· Deadline: 23 Jun 2014
Coroner's Concerns (AI summary)
The coroner noted a failure to immobilise the patient's neck with a cervical collar, despite neurosurgeon's instructions, and that medical staff did not raise concerns about this. The prescribed cervical collar was also not readily available despite the hospital being a regional neuroscience centre.
View full coroner's concerns
(1) Notwithstanding the instructions of the neurosurgeons no effort was made to obtain_ and fit a cervical collar throughout the time he was on the ward. It was fortuitous that the patient did not suffer neurological injury: However; he was at risk of serious injury and death as a consequence of the failure to immobilise the neck (3) Other than the Specialist Registrar no concerns were raised by medical staff that the patient's neck was not properly immobilised both on the ward and on discharge (4) The hospital is a regional centre for neurosciences and neurosurgery the prescribed cervical collar was not available and the Registrar had difficulty locating a suitable collar.
(5) The failure to properly immobilise the neck of patients with fractures of the cervical spine; whether on the instructions of neurosurgeons or otherwise, could those patients at risk of significant disabling injury and death
(5) The failure to properly immobilise the neck of patients with fractures of the cervical spine; whether on the instructions of neurosurgeons or otherwise, could those patients at risk of significant disabling injury and death
Responses
Action Taken
The ED matron discussed communication failures with the nursing team. The hard collar safety alert and other materials related to cervical immobilisation will be redistributed to medical directors, CDs and included in medical staff inductions. A place for central storage of these devices is being looked for within the Emergency Zone and the accessibilily of rigid collars for the purposes of cervical immobllisation is being readdressed since the move into the new Brunel building. (AI summary)
The ED matron discussed communication failures with the nursing team. The hard collar safety alert and other materials related to cervical immobilisation will be redistributed to medical directors, CDs and included in medical staff inductions. A place for central storage of these devices is being looked for within the Emergency Zone and the accessibilily of rigid collars for the purposes of cervical immobllisation is being readdressed since the move into the new Brunel building. (AI summary)
View full response
North Bristol NH NHS Trust Trust Headquarters Southmead Hospital Bristol Southmead Road Westbury-on- Bristol BS1O SNB Tel:0117 41 43816 Websile: http IlwWW nbLIhs uk 20 June 2014 Dr P Harrowing HM Assistant Coroner The Coroner's Court The Courthouse Old Weston Road Flax Bourton BS48 1UL By Fax 01275 462749 Robert Anthony Perkins (deceased) 36 Kipling Road; Northville, Bristol DOB: 7/12 1943 DOD: 16/6/2013 refer to the Regulation 28 report dated 28h April 2014 following the inquest into the death of Mr Perkins, which concluded on the 2Ist March 2014. From investigations it appears that whilst in the Emergency Department (ED) Mr Perkins was too agitated to wear a rigid collar and persistence in trying to put a collar on or even just wearing & collar would likely to have caused more harm and distress to him: Also the ED consultant felt it inappropriate to sedate Mr Perkins for the purposes of applying the collar, again due to the risks of harm from sedation. In the ED there were 2 separate attempts at putting a collar on firstly a hard collar was attempted and then, later on, a Philadelphia collar (significantly more comfortable than hard collars thus better tolerated) Mr Perkins did not tolerate either_ There was a clear decision made by the ED team that they should not persist further in applying a collar: What was not clear was how this was communicated across to the receiving medical team especially with respect to the absolute need for the collar, if this could be tolerated by Mr Perkins, and the timing for attempting to reapply the collar. Following review, the ED matron had discussed this communication failure with the nursing team concerned It is clear that communication of these issues is vital to prevent a recurrence of & similar case It is agreed that communication should include, where there is a failure to apply a rigid collar in the ED, the reasons why the collar was not applied and the nursing aspects for the neck in the interim and when a reattempt at applying the collar should occur_ Since move to the new hospital at Southmead change has occurred in process regarding overall responsibilily for patients Now Acute Admissions Unit (AAU) consultants are in charge of the medical intake 24/7 , (previously the on consullant was in charge in lieu of an acute physician) so there is a clearer of responsibility there is an AAU consultant (i.e. acute physician) on site between 8 am and 10 pm and on call overnight as Peter Rilett Unlverslty of Bristol Teaching Trust Andrea Young Chairman University of the of England Teachlng Trust Chief Executive Trym the call line West
of this Is that there is much less variance in terms of clinicians with overall well, The effect responsibility, now only 8 rather than the previous 24 clinicians. the Clinical Director (CD) of the Medicine Directorate discussed this Following the inquest in particular awareness and understanding regarding case will his neurosurgical colleagues dated October 2011_ The CD will re- the use of collars_ enclose a hard collar safety alert and to other puebliciseothis issue by sending this alert out again to the cedicadDyreafodaaesc include it in Sfhat there is Trustwide distribution in the next few days and also CDs t0 ensure medical staff (Ihe next one will be in August 2014) future medical induction of new collars for the purposes of cervical immobllisation is something that The accessibilily of rigid into the new Brunel building: A place for is also being readdressed now since the movee Zone. By creating centfai storage of these devices is being looked for within the Emeseency where to find location of these devices it should make it easier t0 know single area for the anticipated that this action should be completed by a collar when the device is needed It is the end of June 2014. will also be reported on in part B of the Medical Directorate's clinical The regulation 28 report 2OtepFrom here it will be decided on whether any further governance agenda on 26 June further notification will be made to action needs to be taken; Following this, it is likely that a need to review medical teams to ensure that they are all familiar with the the directorate's is admitted with cervical neck injury and plans for cervical immobilisation when a the location of the rigid collar devices_ exceptional case in the Medical Directorate;
i.e., a dying In conclusion, Mr Perkins was an have collar fitted in ED, for the man who was confused and difficult to manage who did suffer further above_ However , agree it was fortuitous he did not reasons explained substandard in AAU, and trust the implementation of disability, that his management was similar issues in the future. the above will prevent a recurrence of these or
of this Is that there is much less variance in terms of clinicians with overall well, The effect responsibility, now only 8 rather than the previous 24 clinicians. the Clinical Director (CD) of the Medicine Directorate discussed this Following the inquest in particular awareness and understanding regarding case will his neurosurgical colleagues dated October 2011_ The CD will re- the use of collars_ enclose a hard collar safety alert and to other puebliciseothis issue by sending this alert out again to the cedicadDyreafodaaesc include it in Sfhat there is Trustwide distribution in the next few days and also CDs t0 ensure medical staff (Ihe next one will be in August 2014) future medical induction of new collars for the purposes of cervical immobllisation is something that The accessibilily of rigid into the new Brunel building: A place for is also being readdressed now since the movee Zone. By creating centfai storage of these devices is being looked for within the Emeseency where to find location of these devices it should make it easier t0 know single area for the anticipated that this action should be completed by a collar when the device is needed It is the end of June 2014. will also be reported on in part B of the Medical Directorate's clinical The regulation 28 report 2OtepFrom here it will be decided on whether any further governance agenda on 26 June further notification will be made to action needs to be taken; Following this, it is likely that a need to review medical teams to ensure that they are all familiar with the the directorate's is admitted with cervical neck injury and plans for cervical immobilisation when a the location of the rigid collar devices_ exceptional case in the Medical Directorate;
i.e., a dying In conclusion, Mr Perkins was an have collar fitted in ED, for the man who was confused and difficult to manage who did suffer further above_ However , agree it was fortuitous he did not reasons explained substandard in AAU, and trust the implementation of disability, that his management was similar issues in the future. the above will prevent a recurrence of these or
Sent To
- North Bristol NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
23 Jun 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 9th July 2013 commenced an investigation into the death of Mr Robert Anthony Perkins age 69 years. The investigation concluded at the end of the inquest on 21st March 2014, The conclusion of the inquest was that the medical cause of death was I(a) Metastatic bladder cancer; Il Vertebral Fracture, Fall and the short-form conclusion was that the death was due Natural Causes"
Circumstances of the Death
Mr. Perkins was admitted to the Emergency Department of Frenchay Hospital on Sth June 2013 where he arrived at around 12.30 hours_ He suffered with terminal cancer and had suffered a fall at home that morning_ He was confused, agitated and complaining of posterior neck pain. On examination he had a large focal swelling over C4 C6 with tenderness_ A CT scan showed that he had suffered a compression fracture of C5 with marked angulation. Advice was sought from the neurosurgeons who considered that in the context of his terminal cancer with poor prognosis the fitting of a Philadelphia neck collar would be the appropriate sole treatment: It was noted that Mr, Perkins was due to be admitted to a hospice for terminal care. However, a bed was not immediately available at the hospice and Mr. Perkins was admitted to the ward overnight Despite the instructions of the neurosurgeons no collar was fitted. Mr. Perkins was seen that evening by the consultant on the post-take ward round and he was seen again the following morning, the Gth June 2013, when still no collar had been fitted: That same morning Mr. Perkins was discharged to the hospice_ He was seen by the Specialist Registrar in Medicine being escorted in a wheel chair by ambulance personnel: The Registrar, who in evidence, stated he had not seen Mr; Perkins before identified that Mr. Perkins should have a collar fitted and he was returned to the ward The Registrar, who had neurosurgical experience, considered it to be unsafe for Mr. Perkins to be transferred without wearing a collar and decided to fit one as had been instructed by the neurosurgeons There was no collar available on the ward and the Registrar spent some time visiting_ other wards departments to obtain a Philadelphia collar but could not locate one in the hospital: Eventually he obtained a Miami J Collar with assistance this collar was fitted and Mr. Perkins discharged to the hospice. When Mr. Perkins arrived at the hospice it was discovered that one of the collar may have been fitted incorrectly causing him discomfort and it was removed_ Mr, Perkins remained at the hospice where he died on 16th June 2013
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action: and and part yet place and
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.