Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0038, written 27 Jan 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Jan 2014 |
|---|---|
| Reference | 2014-0038 |
| Deceased | Umul Audu |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University College London Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) Chief Executive University College London Hospitals NHS Foundation Trust 1 CORONER I am R Brittain, Assistant Coroner for Inner North London 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST The investigation into the death of Umul Kelsum Anna AUDU, aged 25, was commenced on 23 October 2013 and concluded at the end of the inquest on 24 January 2014. The conclusion of the inquest was narrative 4 CIRCUMSTANCES OF THE DEATH Anna Audu was admitted to A&E at University College Hospital on 10 October 2013 with symptoms of headache and back pain. She was treated for both bacterial and viral illnesses, which resulted in her being prescribed a number of medications. She subsequently developed a rash, which rapidly progressed to Toxic Epidermal Necrolysis (TEN). The cause of this condition may have been an infection, or a medication that Miss Audu was prescribed. However, a definitive cause was not able to be elucidated at the inquest. The development of TEN necessitated Miss Audu’s admission to the Intensive Care Unit (ICU), in an attempt to treat the organ failure and fluid/heat loss which results from this condition. Miss Audu underwent a CT and MRI scan on 15 October, which caused her to be away from the ICU for a period of three hours. Documentary evidence was presented at the inquest that there is no ‘transport heater’ available on the ICU to enable warming of patients whilst they are away from the unit. On Miss Audu’s return from the imaging department she was hypothermic. Further evidence, presented in writing by the treating clinician, set out that this period of hypothermia did not result in any adverse consequences and did not therefore contribute to Miss Audu’s death, when she succumbed to the effects of TEN on 20 October 2013. 5 CORONER’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. 1 The MATTERS OF CONCERN are as follows. – (1) The lack of transport heater availability was not explained in the written evidence presented by the Trust. I did not judge it appropriate to adjourn the inquest in order to obtain further written or live evidence on this point, as sufficient information was available in order to conclude matters on 24 January 2014. However, it remains a concern that, in similar circumstances, the lack of transport heater could result in future patients becoming hypothermic on transfer, which might result in their death. As such, I am making this report in order that the Trust can respond to this concern. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Executive of the Trust, have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24 March 2014. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner, Miss Audu’s family and The Care Quality Commission. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a 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. 9 27 January 2014 Assistant Coroner R Brittain 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
1 2 3 4 RESPONSE TO REGULATION 28 CORONER’S REPORT TO PREVENT FUTURE DEATHS THIS RESPONSE IS MADE ON BEHALF OF University College London Hospitals NHS Foundation Trust REGULATION 28 REPORT This response follows a report by Assistant Coroner Dr R Brittain dated 27 January 2014. INVESTIGATION AND INQUEST The inquest in question relates to the death of Umul Kelsum Anna AUDU who died at University College Hospital on 20 October 2013. Her inquest was concluded on 24 January 2014. CIRCUMSTANCES OF THE DEATH On behalf of the Trust I have carried out a full investigation into the case and in particular examined the events around her transfer for imaging at which time a period of hypothermia is documented. Normal human body temperature in adults is 34.4-37.8ºC (93.9-100ºF). Hypothermia is defined as any body temperature below 35ºC (95ºF). Hypothermia is classified in 4 different grades with mild hypothermia relating to 32-35ºC (90-95ºF). There are 3 further grades below this and to put this specific case into context, the lowest temperature documented was 33.6ºC, thus classified as mild hypothermia. Your conclusion was that no adverse consequences occurred as a result of this period of hypothermia and that also represents my view. Based on documentary evidence at inquest you have noted that there was no transport heater available on the ICU to enable warming of patients whilst they are away from the unit. You have noted as a matter of concern that the lack of transport heater availability was not explained in the written evidence presented by the Trust. This had not been identified as an issue prior to the hearing and on reflection the statement provided on our behalf may have been misleading. The position in fact is that we do not use transport heaters within the Trust and we believe that this is in line with national practice. At present although transport heater devices do exist to prevent hypothermia, they are not routinely used for patient transfer in UK hospitals. Furthermore, there is no specific guidance from any of the Critical Care Society suggesting adults should be actively warmed with this devices during transfer for investigations. The current advice is that standard measures to avoid hypothermia are routinely used during transfer, as in fact occurred in this case. More specifically, MRI scanning (the investigation that the patient in question underwent) is even more problematic. Transport heater devices such as warming blankets contain metallic elements, which are absolutely contraindicated for use in the MRI environment, and indeed there are reports in the literature of patients being burnt in MRI scanners when such devices have been used. 5 CORONER’S CONCERNS As an organisation we are mindful of our duty to consider your report and indeed I have carried out a full investigation into the case. 1 In reviewing the case, I have sought the advice of my colleagues in Critical Care at UCLH and discussed the case at our Divisional Clinical Governance meeting. In addition, the case was discussed in detail at our joint Critical Care Collaboration Group meeting at which all of the clinical leads at the ICUs at UCLH (UCH Tower, ITU, Heart Hospital at ITU and the National Hospital for Neurological Diseases ITU) attended. Our considered position based on these enquiries and the views of my colleagues is that at present we would not propose to change our policy and introduce transport heaters for the reason set out above. That is: (i) (2) (3) We believe that standard measures to avert hypothermia will protect patients from any significant harm and will avoid any risk of future death Our current practice is in line with national standards There are positive contraindications to using such devices for some investigations and their introduction could increase risk to patients of harm. We will however be keeping the position under review. It is a complex issue and at present we do not believe simply introducing transport heaters is appropriate and, for the reason stated, based on our investigations we do not believe that a lack of transport heater availability in itself could give rise to a risk of future deaths. 6 ACTION TAKEN/TIMESCALE (1) We have carried out a full investigation. (2) We will keep this issue under review but at present would not propose to introduce transport heaters for the reasons set out above. (3) We would be happy to provide further details regarding our considered view if this would assist you. THIS RESPONSE HAS BEEN PREPARED BY , Divisional Clinical Director, Critical Care, UCLH DATE OF RESPONSE 24 March 2014 7 8 2
See every Prevention of Future Deaths report matching University College London Hospitals NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.