Peter Brookes

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 TO PREVENT FUTURE DEATHS

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This response foliows a report by R Brittain, Assistant Coroner for Inner
North London dated 7™ May 2014

INVESTIGATION AND INQUEST

The inquest in question relates to the death of Peter John BROOKES,
who died at University College London Hospital on 27th August 2013.
His inquest was commenced on 3 September 2013 and concluded on 30

CIRCUMSTANCES OF THE DEATH

Mr Brookes had a background medical history which included
Parkinson’s disease (PD) and ischaemic heart disease. He was admitted
to University College Hospital (UCH) in early August 2013 for removal of
a cancerous skin lesion. He was catheterised postoperatively. This
resulted in some bleeding, which was thought to be resolving and the
catheter was removed. The bleeding recurred, which resulted in a short
readmission to UCH and warranted reinsertion of a catheter.

April 2014. The conclusion of the inquest was narrative.

Mr Brookes was admitted for a third time on 17 August after the catheter
became blocked. During this admission there were issues regarding the
sourcing and administration of Mr Brookes’ PD medication, meaning that
he did not receive his medication as prescribed. On 18 August Mr
Brookes had a period of ‘agitation’ and rapid breathing, which the nursing
staff felt warranted review by the ward doctors, although his symptoms
did resolve after administration of pain relief. This review did not occur
despite repeated requests from the nursing staff. | heard evidence that
weekend ward rounds routinely take most of the day to complete, which
might mean that the on call team were so busy that nonemergency
reviews would not occur.

in the morning of 19 August Mr Brookes suffered a respiratory arrest,
which resulted in his admission to the Intensive Care Unit (ICU).
Subsequent investigations demonstrated that Mr Brookes had suffered a
heart attack. Whilst on the ICU it was discovered that one of the PD
medication boxes (Amantadine) actually contained another medication,
as a consequence of a dispensing error in the hospital pharmacy. There
was no evidence that Mr Brookes had been administered the wrong
medication.

Mr Brookes developed bronchopneumonia and continued to deteriorate,
despite ongoing medical treatment. He died on 27 August 2013.

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CORONER’S CONCERNS

As an organisation we are mindful of our duty to consider your report and
indeed | have carried out a full review of the issues raised. | have sought
advice from a number of areas, including the head of pharmacy and

1

RESPONSE TO REGULATION 28 CORONER’S REPORT TO
PREVENT FUTURE DEATHS

divisional clinical director for clinical support, clinical nurse specialist for
Parkinson’s Disease, a consultant neurologist and clinical leads and
managerial staff for the Urology specialty.

The MATTERS OF CONCERN are as follows. —

(1) The administration of PD medication in hospital routinely does not
follow patients’ usual regimens and that this, in itself, could cause
physiological stress and contribute to early death. It was not possible
conclude that, on the balance of probabilities, this was the case in Mr
Brookes death but it was clear that this was a continuing risk, which could
result in future deaths.

(2) The risks posed by the unavailability of doctors for nonemergency
reviews, during weekend shifts, raises concern that future deaths could
occur as a consequence.

(3) The cause of the dispensing error, that resulted in the wrong
medication being put in a box labelled as ‘Amantadine’, was not
elucidated during the inquest and raises concern that future similar errors
could recur, with potential for future deaths resulting.

[6 | ACTION TAKEN/TIMESCALE

(1) | heard evidence that the administration of PD medication in hospital routinely does

not follow patients’ usual regimens and that this, in itself, could cause physiological

stress and contribute to early death. It was not possible conclude that, on the balance

of probabilities, this was the case in Mr Brookes death but it was clear that this was a
continuing risk, which could result in future deaths.

The Trust recognises the importance of ensuring medications, particularly those
relating to PD and other time sensitive medication are taken in accordance with the
patient's usual medication schedule. A key approach to this in the Trust’s specialist PD
area_ is through promoting and encouraging self medication where appropriate.

In order to ensure staff across the Trust are alerted to the critical importance of
ensuring PD patients take their medication on time the following actions will be taken.

Completion date

An item to be included in the July
Quality and Safety newsletter.
Link to Parkinson’s Disease website
and reference to ‘Get it on time’ video
to be included in the Q&S newsletter.
Awareness to be raised via the Trust
Clinical Practice Facilitators forum.

July 2014

August 2014

RESPONSE TO REGULATION 28 CORONER’S REPORT TO
PREVENT FUTURE DEATHS

(2) The risks posed by the unavailability of doctors for nonemergency

reviews, during weekend shifts, raises concem that future deaths could occur as a
consequence.

The Trust has systems in place for the provision of urgent and non urgent medical
cover over the weekend period. For Urology in particular there is:

e A Urology ward Senior House Officer (SHO) post which provides essential cover
for the elective wards (T6 and 710) from 8am — 5pm performing general duties
and ward reviews.

e Asurgical Senior House Officer (SHO) post which provides emergency surgical
cover primarily to Accident and Emergency Department

e AUrology Specialty Registrar (SpR) who performs daily ward rounds on elective
ward rounds accompanied by the ward SHO. The SpR works Saturdays and
Sundays and is available on an on call mobile phone 24/7 and must be no more
than 1 hour away from the hospital at any one time.

e Anon call Urology consultant who provides support and advice as needed and
attends the hospital when required.

The SHO is usually contacted via the hospital bleep system. However, if the nursing
staff are unable to make contact via the bleep system for whatever reason (which was
the situation which arose with Mr Brookes) they are advised to contact the medical staff
via their mobile phones. A staff directory provided to the wards on a quarterly basis
(most recently circulated in June 2014) contains numbers for clinical and managerial
staff in the Urology specialty. If the SHO cannot be contacted nursing staff are
instructed to escalate through the medical cover system to senior registrar and
consultant level if necessary this would be supported by the ward sister or charge
nurse for this area. At weekends the same escalation system would apply but with site
practitioner available to support nurses escalating based in the operations centre rather
than ward sister. During evenings (8.00pm — 8.00am) this process of escalation is
managed by the hospital at night team service. A nurse unable to contact a Senior
House Officer by bleep would escalate through the night triage system which is led by
the night site practitioner based in the operations centre

The escalation process has recently been included in nursing staff local induction to
ensure that all new starters are clear of the escalation process and where to access
the staff directory which is saved on a shared server and physically stored in folders on
the ward.

The system of cover was further strengthened in November 2013 by the introduction of
an ‘SpR of the week’ on call rota rather than a 12 hourly rotation. The Urology SpR of
the week is dedicated entirely to on call duties and is available for both ward and A&E
patients at both weekends and during the week (8am — 8pm). This has reduced the
number of handovers which is where there is the possibility of actions being missed.

A further action to raises awareness of escalation processes across the Trust will be
undertaken via the Jul Quality and Safet newsletter.

3

RESPONSE TO REGULATION 28 CORONER’S REPORT TO
PREVENT FUTURE DEATHS

(3) The cause of the dispensing error, that resulted in the wrong medication being put
in a box labelled as ‘Amantadine’, was not elucidated during the inquest and raises
concern that future similar errors could recur, with potential for future deaths resulting.

The Trust recognises that medication errors relating to the prescribing, dispensing and
administration of medications is a key risk facing all NHS Trusts. In recognition of this
the Trust has an ongoing and comprehensive risk reduction programme in place. In
relation to dispensing errors in particular there were a number of routine processes in
place to minimise the risk prior to the error. These are:

e Independent double check in place for dispensed medicines.

e The majority of medications are stored in and dispensed from pharmacy robots
to minimise picking errors

e Where packs are not able to be stored in the robot — similar looking/sounding
drugs are stored in separate areas to try and avoid possible picking errors

e We use Tallman lettering (the practice of writing part of a drug's name in upper
case letters to help distinguish sound-alike, look-alike drugs from one another in
order to avoid medication errors)

e All dispensers are trained pharmacy technicians or assistants and complete
dispensing logs during induction to ensure that they are competent in the
dispensing process

e Allcheckers are pharmacists or qualified accredited checking technicians and
have to complete checking logs to ensure competence

e Any dispensing/checking errors that leave the pharmacy department are
thoroughly investigated

e All pharmacy incidents are reviewed at the pharmacy clinical governance
meeting and actions plans monitored when appropriate

Following the error other changes have been implemented which further minimise the
risk:

e Assystem of continuous monitoring of ‘in process’ dispensing errors (i.e. errors
picked up at the checking stage) has been implemented. This data is reported
and reviewed monthly for all dispensary areas and for all dispensing staff in the
trust.

e Staff (both dispensers and checkers) involved in any errors that leave the
department are required to complete reflective statements as to why they felt the
error occurred and include self-reflection on lessons learnt to try and prevent a
re-occurrence. They are also required to complete checking/dispensing logs to
assess competency.

e Dispensing errors and any themes identified are shared with staff at dispensary

meetings to raise awareness and share learning to avoid similar occurrences.

THIS RESPONSE HAS BEENE REPARED BY

Professor

DATE OF RESPONSE
2" July 2014