UK Inquiry Tracker

Elsie May Treece

PFD Report All Responded Ref: 2013-0376

Date of Report 16 December 2013

Coroner Andrew Haigh

Coroner Area Staffordshire (South)

Response Deadline est. 10 February 2014

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 10 Feb 2014

Coroner's Concerns (AI summary)

Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the requirement to report all inappropriate incidents.

View full coroner's concerns

_ (1) received information from the family that on the afternoon of the 26 July 2013, following difficulties in moving Mrs Treece, for a while hospital staff left one Of Mrs Treece's daughters (aged 70) supporting her mother. One of them then returned with a blue lifting bag with handles but she was not properly supported and fell back heavily on the bed with some force Investigation has been carried out by the Ward 6 manager and received report which indicates there is no record of any such incident either in paper records , electronic records or speaking to staff on duty: did not investigate this incident fully because on balance it is unlikely to have been significant so far as the death is concerned. However the view took on the evidence did hear was that there had been an incident which should have been reported and may well not have been_ therefore write to you to enquire if staff need to be reminded or may need further training regarding the requirement to report inappropriate _incidents even if no major _harm seems to come to the patient_ May from involved_ (2) While writing to you perhaps could also find out for me the reasons why Mrs Treece did not have a CT scan of her head following the attendance on the 18 July 2013. This is not strictly a matter for this formal report but an answer would be appreciated.

Responses

Burton Hospitals NHS NHS / Health Body

31 Jan 2014

Action Taken
Burton Hospitals NHS has always provided training for staff in relation to incident reporting, and they have arranged to provide additional training and support for Ward 6. They have linked in with the University to raise awareness with student nurses surrounding the importance of incident reporting. (AI summary)

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Dear Mr Haigh Re: Elsie TREECE (Deceased) In response to the HM Coroner's Prevention of Future Death Report received by the Trust following the inquest of Elsie Treece [B332952]. In relation to incident reporting, can confirm that training has always been provided for staff in relation to the reporting of incidents. This training has been delivered by the Clinical Risk Team in collaboration with the Learning and Development Team: Registers of attendance are collated by the Learning and Development Team and entered against the annual training requirements for each staff member and uploaded onto the ESR system: Currently training is provided at Trust induction days, mandatory update training days, online training and ad hoc sessions in ward and department areas and provided for medical staff in different forum_ Ad hoc training is provided as requested, and in light of this request for information from HM Coroner; we have arranged to provide additional training and support for Ward 6. More recently, we have linked in with the University to raise awareness with student nurses surrounding the importance of incident reporting and the feedback mechanisms Which occur Whilst it has been acknowledged that there was period of downtime for the HISS computer system which occurred the time of Mrs Treece's admission, contingency plans were in place which instigated the use of paper based documentation, and including paper based incident forms_ Those paper incident forms received during and following the downtime were manually entered into the electronic system. With regard to point 2 of concern as to the reasons why Mrs Treece did not have a CT scan. Please find attached letter from Joutlining the reasons why a CT scan was not appropriate_ Yours sincerely 793 LY Helen Ashley Chief Executive: Att_ WKZO2SA May May during put

Burton Hospitals [NH NHS Foundation Trust Queen's Hospital Belvedere Road Burton upon Trent Staffordshire DE13 ORB ref JACIEG Telephone 23 January 2014 BURTOWh eriAL3NHS JAUST T2 ?leCAL SeAvICES ' Legal Services Manager T Queen's Hospital Jam Bridget Re: Elsie Treece DoB: 2/6/1918 Mr Haigh has asked Trust to look at the case of Mrs Elsie Treece who the Emergency Department on 18 2013 at 0317hrs specific attended to find out why Mrs Treece did not have CT scan on that question was She was seen by Foundation Year 2 Doctor at 04OOhrs , after triage which showed that she was alert with normal observationste routine assessed her noted that she was suffering from The Doctor who her bed, where she landed a head injury, following a fall on the She sustained a laceration to the right forehead, without any evidence of loss of consciousnees, her normal conscious level. He also noted vomiting or reduction in alert and that she was not on Warfarin and was comfortable on examination. have also looked at the West Midlands Ambulance Service regarding her transfer t0 the EmergencyaDepartmenlaand agairicehidocorroeoraiog thee Doctors notes where there was no evidence of loss of consciousnessr she was alert with a normal conscious level. and also Her symptoms and signs were not consistent with significant head injury and therefore Wehwould not have proceeded to do a CT scan as per NICE head guidance. There was no indication to out a CT scan at the time: thanks

Sent To

Burton Hospitals NHS Foundation Trust

Response Status

Linked responses 1 of 1

56-Day Deadline 10 Feb 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 5 August 2013 / commenced an investigation into the death of Elsie Treece aged 95. The investigation concluded at the end of the Inquest on 11 December 2013. The conclusion of the Inquest was accidental death CIRCUMSTANCES OF THE DEATH On 18 July 2013 Mrs Treece had a fall in the care home where she lived, attended Queen's Hospital in Burton and was returned home. On 24 July she had another fall and this time was admitted to Queen's Hospital with a broken arm and an inoperable bleed to her brain: The head injury caused her death at the hospital on 2 August: CQRONER'S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken_ In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows - (1) received information from the family that on the afternoon of the 26 July 2013, following difficulties in moving Mrs Treece, for a while hospital staff left one Of Mrs Treece's daughters (aged 70) supporting her mother. One of them then returned with a blue lifting bag with handles but she was not properly supported and fell back heavily on the bed with some force Investigation has been carried out by the Ward 6 manager and received report which indicates there is no record of any such incident either in paper records , electronic records or speaking to staff on duty: did not investigate this incident fully because on balance it is unlikely to have been significant so far as the death is concerned. However the view took on the evidence did hear was that there had been an incident which should have been reported and may well not have been_ therefore write to you to enquire if staff need to be reminded or may need further training regarding the requirement to report inappropriate _incidents even if no major _harm seems to come to the patient_ May from involved_ (2) While writing to you perhaps could also find out for me the reasons why Mrs Treece did not have a CT scan of her head following the attendance on the 18 July 2013. This is not strictly a matter for this formal report but an answer would be appreciated. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you or your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10 February 2013. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action; Otherwise you must explain why no action is proposed. COPIES and PUBLICATION sent a copy of my report to the Chief Coroner and to the following Interested Persons: daughter of Mrs Treece Legal Services Manager, Queen's Hospital and Manager, St Mary's Mount Residential Home_ have also sent it to Mr Derek Winter HM Senior Coroner for the City of Sunderland and the Care Quality Commission who may find it useful or of interest. am also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in complete or redacted or summary form: He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me; the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner: 16 December 2013 Iy Andrew A Haigh HM Senior Coroner Staffordshire (South) you have AL

Circumstances of the Death

On 18 July 2013 Mrs Treece had a fall in the care home where she lived, attended Queen's Hospital in Burton and was returned home. On 24 July she had another fall and this time was admitted to Queen's Hospital with a broken arm and an inoperable bleed to her brain: The head injury caused her death at the hospital on 2 August:

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you or your organisation have the power to take such action.