Graham William FOX · Prevention of Future Deaths report

On 12th July 2017 an investigation commenced into the death of Graham William FOX. The investigation concluded at the end of the inquest on 8 June 2018. The conclusion of the inquest was that he died of (Ia) chronic obstructive pulmonary disease and pneumonia, and (II) left hip fracture (operated) and ankle fractures.

My narrative conclusion included the following:

His condition deteriorated, and overnight from 25 June hospital staff did not correctly implement the standardised method of assessment and referral [‘NEWS’] that was in use at the time, which meant that he was not seen by a doctor as he should have been, and the seriousness of his condition was not recognised until 26 June, when he was admitted to the Critical Care Unit in which he subsequently died.

Mr Fox had a history of alcohol misuse and had had a fall in the community in which he broke both ankles. He was admitted to hospital and was being monitored using the NEWS system. He had been “re-triggered” by the hospital’s doctors, so that although normally an oxygen saturation, or a blood pressure reading, below a certain level would add points to the NEWS total, in Mr Fox’s case points would not be added unless his score dipped below the new revised (“re-triggered”) level.

Mr Fox’s ‘normal’ NEWS was 5, after which he was reviewed, “re-triggered”, and when later assessed his score was 5 again (using the new re-triggered means of assessment). That represented a real-world deterioration in his condition, but because the number itself did not go up, the nursing staff were relatively unconcerned. The NEWS of 5 was in due course relayed to the on-call doctor, but the doctor did not attend, even though she was on the same ward seeing another patient that evening.

Mr Fox then had a series of inadequate observations taken overnight (which were not sufficient to enable any calculation of his NEWS total). By the time his NEWS total was properly calculated in the morning it was 9: he was then admitted to the Critical Care Unit, where his condition deteriorated and he sadly died.

(1) The standard NEWS documentation contains a list of scores on the left, and corresponding clinical responses in a column on the right. My understanding of the system was that when the relevant score was reached, the corresponding clinical response was mandatory. The impression I gained from listening to the majority of the nursing staff was that there was an element of discretion / clinical judgment to be applied in determining whether the clinical responses that were ‘required’ when the relevant score was reached were actually necessary. The more senior nursing staff were clear that the relevant responses were mandatory, but that was not the impression given by the more junior staff. This evidence (which gave the impression that staff discretion could be applied to the clinical responses) was given after the staff had, apparently, been given additional NEWS training following Mr Fox’s death.

(2) I did not have the benefit of any expert evidence about the process of “re-triggering” patients under NEWS, and I am therefore unable to comment on whether it is clinically appropriate. I did hear evidence that the practice was commonplace within the hospital.