Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0168, written 14 Apr 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Apr 2014 |
|---|---|
| Reference | 2014-0168 |
| Deceased | Nicos Michael |
| Coroner | Rebecca Cobb |
| Coroner area | North East Kent |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East Kent Hospitals University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
\ yy rm rc REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, East Kent Hospitals University NHS Foundation Trust 1 | CORONER | am Rebecca Margaret COBB, Senior Coroner, for the Coroner area of North-East Kent 2 | CORONER’S LEGAL POWERS | 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 On 25" July 2013 | commenced an Investigation into the death of Nicos Andreas MICHAEL, aged 65 years. The Investigation concluded at the end of the Inquest on 1s April 2014, The conclusion of the Inquest was a Narrative (as set out in the first paragraph of box 4 below, the clinical cause of death being : ta. Acute Anaphylaxis to intravenous penicillin. 2. Abdominal aortic aneurism (operated). 4 | CIRCUMSTANCES OF THE DEATH Mr. Michael died on 1st November 2013 in Kent and Canterbury Hospital, Ethelbert Road, Canterbury, Kent as a result of an acute anaphylactic reaction to Augmentin that was administered intravenously to him at the hospital at around 5.15pm on 30 October 2013 in Kent Ward despite the existence of an old hospital record of a reaction to Augmentin, although there was conflicting evidence as to whether Mr. Michael had on this admission given information of penicillin being one of his allergies. He had informed his dentist of that allergy, but his GP only had a record of an adverse reaction to Ibuprofen. Mr MICHAEL was admitted to the hospital on 28!" October 2013 for an elective repair of his abdominal aortic aneurism, which was carried out later that day. On 30'" October 2013 his blood pressure was elevated, his oxygen saturations were low and he complained of feeling hot, dizzy and nauseous, although his temperature was within normal range. Uitimately, he was administered intravenous Augmentin antibiotic and almost immediately suffered a cardiac arrest which caused a significant brain injury from which recovery was not possible. Active treatment was withdrawn, with the consent of his family, and he died on the Intensive Care Unit on 1st November 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. The MATTERS OF CONCERN are as follows. — (1) There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which he/they was/were aware he was allergic. This led to there being conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the allergy information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen). (2) The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary entry to suggest that at a past medical attendance a reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP. (3)The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital's staff when next treating that patient cannot be over-emphasised. There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However, the evidence also showed that the medical reporting and computer systems for patient tracking do not currently allow this facility in such a way, although the relevant Trust teams are investigating how this data recording can be made more accurate. (4) Although the Trust has indicated that electronic prescribing should now be prioritised (which it considers could potentially have flagged up the historic allergy documentation), the RCA gave no indication that this would be compulsory for the future, or that any steps were being taken to encourage or make compulsory the checking of earlier paper records for information contained therein on allergies. ACTION SHOULD BE TAKEN in my opinion, urgent action should be taken to prevent future deaths and | believe you and 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 9!" June 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. COPIES and PUBLICATION | have sent.a copy of my report to the Chief Coroner and to the following Interested a | | have also sent it to the Chief Executive of the Care Quality Commission and the Secretary of State for Health, Department of Health. 1am 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. 14" April 2014 ~ . pri 0 2 roverca= Cosy = —
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.
East Kent Hospitals University NHS NHS Foundation Trust Trust Offices Miss R Cobb 3 HM Senior Coroner North East Kent Area Kent & Canterbury Hospital 5 Lloyd Road see pterbay Broadstairs Kent CT1 3NG Kent CT10 1HX Tel: 01227 866308 Your ref RC/MAB/MIC/T Our Ref: SB/HG/hp 30 April 2014 From the Chief Executive: Stuart Bain Dear Ms Cobb Re: Nicos Andreas MICHAEL deceased Following the conclusion of the Inquest hearing into the death of Mr Nicos Andreas MICHAEL on 01 April 2014 and your subsequent letter dated 14 April 2014 pursuant to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, | write to inform you of the actions and considerations taken ~ by East Kent Hospitals University NHS Foundation Trust. | note the concerns raised in your letter regarding the recording of a reported allergy to penicillin throughout the healthcare records pertaining to Mr Michael. | am concerned that the issues that you highlight are based solely on the findings of the Root Cause Analysis undertaken into this case and the various statements provided by the staff involved in the care and treatment of Mr Michael. There were no members of staff called to the Inquest into Mr Michael’s death who may have been able to respond to your specific questions on this matter and explain the current process for recording allergies to you more clearly. | will comment on your findings in the order they appear in your report. 1. There was no consistently recorded allergy to penicillin contained in the healthcare records held by the Trust. Indeed the patient himself did not articulate an allergy to penicillin at his pre-operative assessment; he did state allergies to Ibuprofen and Aspirin and red “known allergy” wristbands were applied from the date of his admission. The staff on ICU and on Kent Ward were all aware of Mr Michael’s reported allergies. 2. There was a single reference to an allergy recorded in one volume of records embedded within the Surgical Integrated Care Pathway. The type of allergy/sensitivity was not quantified in any way. The allergy was not documented in any prior or subsequent set of ee _ fie Putting patients first
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