Maureen Harrop
14 Sept 2022 · Coroner Alison Mutch · Manchester South
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delayed surgery for neck of femur fracture
“The inquest heard that Mrs [name redacted] had a prolonged stay in the ED at the Hospital because of lack of bed capacity”
2. delayed surgery beyond 36 hours
“The evidence at the Inquest was that the NICE guidance promotes surgery within 36 hours”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“Mrs [name redacted] had a prolonged stay in the ED at the Hospital because of lack of bed capacity.”
Later report
“long waits for transfer to hospital and delays in being transferred to wards presented a significant risk to the health and wellbeing of elderly frail patients with hip fractures”
Closely relatedConfidence 0.80 · moderate
This report
“The evidence at the Inquest was that the NICE guidance promotes surgery within 36 hours. In Mrs [name redacted] case that was not achieved due to a lack of theatre capacity.”
Later report
“There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding; and wards having to undertake elective and emergency work at the same time.”
Responses
2022-0285-Response-from-NHS-England-.pdf ↗· NHS England
Stated action
“The Trust has now been able to reinstate previous care pathways due to a decline in the national incidence of Covid positive cases. This means that the bed base of trauma and orthopaedics has been increased to near pre- pandemic levels”
Stated action
“The trauma and orthopaedic department run a daily trauma meeting, where all patients with hip fractures who are awaiting surgery are identified. Individual plans of care and management are agreed clinically with the on-call orthopaedic consultant and trauma coordination team. An overview of these patients is also provided to the surgical bed meeting each morning, including the status of each patient and the current wait time for surgery.”
Stated action
“For those patients who can proceed to surgery, this will be scheduled to take place within the 36 hour timeframe to support compliance with NICE guidance. If this is not possible due to a theatre not being available, an urgent review of the entire trauma and elective lists that day will be undertaken. A clinical and operational discussion determines how the patient can be accommodated, and a plan is then devised. The detailed plan is then enacted with the approval of the Divisional Management Team”
Stated action
“The Trust also submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture. This includes data to improve care through quality improvement, in line with NICE guidelines and the National Falls and Fragility Fracture Audit Programme (FFFAP). Data is submitted by the trauma coordinators daily.”
Stated action
“the Trust has implemented a Divisional fractured neck of femur improvement programme, which is reported and monitored daily via the Divisional senior leadership team. Oversight of Divisional compliance with this pathway is also monitored via the Service Quality and Governance Group, which is chaired by the Executive Director of Nursing and Integrated Governance.”
Stated action
“Following the incident, a root cause analysis (RCA) is completed by the trauma coordinators to identify the reasons for the delay and opportunities for learning. The RCA investigations are reviewed weekly in the”