Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0209, written 9 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 May 2014 |
|---|---|
| Reference | 2014-0209 |
| Deceased | Abiola Dosunmu |
| Coroner | Andrew Walker |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
(1) Mr Tim Smart, Chief Executive, King’s College Hospital NHS Foundation Trust,
Denmark Hill, London SE5 9RS
CORONER
[am Dr Andrew Harris, Senior Coroner, London Inner South
CORONER'S LEGAL POWERS
1 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.
INQUEST
On 4th September 2012, | opened an inquest into the death of:
Miss Abiola Dosunmu, aged 17 years, died 24th August 2012, Case
Ref: 02054-12,
It was concluded on 16th April 2014.
The court found that the medical cause of death was:
ja Acute Renal Failure
1b Systemic Lupus Erythematosus
CIRCUMSTANCES OF THE DEATH
The following narrative was recorded:
Ms Dosonmu developed a swollen leg, a DVT being excluded at hospital on 22.02.12
and treated with antibiotics. She was found by her GP to have abnormal blood tests
(ESR over 100 and CK over 6000) but when seen on 29.02.12 it does not appear these
were discussed. The GP intended her to attend A&E but she did not. She is referred
urgently to hospital by the GP on 07.03.12 with presumed cellulitis of her left leg, which
is treated with intravenous antibiotics as an inpatient. She was found to have 3+
proteinuria but this information was not transmitted form the A&E department to
clinicians on the ward before she died, who assumed with normal renal blood tests that
she had normal renal function. She self discharged on 09.03.12 against medical advice,
but neither the family nor GP were informed of the need to repeat her high ESR and CK,
Abiola declined further tests on 23.03.12 when she had lymphadenopathy. The GP
referred her to a haematologist by fax on 30.03.12, the fax not being received by the
consultant. On 10.04.12 further blood tests were abnormal (ESR still 120), and Abiola
was again asked to attend surgery to discuss them, but she did not.
Her mother did not enquire about the results of the tests although she had a routine
letter requesting she discuss them with her GP, as Abiola was getting better and she
(her mother) did not understand that they were abnormal, and the doctors at the surgery
and hospital did not follow up the monitoring of these. On the balance of probability the
very high ESR which persisted (and proteinuria had it been known outside A&E) were
signs of the underlying connective tissue disorder causing renal disease.
Her symptoms settled but she rapidly deteriorated on 22nd and 23rd August with
progressive swelling of her body, due to nephrotic syndrome and was found dead at
home on the morning of 24th August, certified at 08.51 by the emergency services. She
died from the complications of SLE. There were missed opportunities to diagnose and
treat it earlier. Abiola did not comply with medical advice. The abnormal proteinuria test
was not identified by those treating her in hospital. The significance of abnormal blood
tests was not communicated to the family. These factors on the balance of probabilities
more than minimally or trivially contributed to her death. |
5 | CORONER’S CONCERNS
During the course of the inquest the evidence revealed maiters 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 is as follows. —
(1) The 3+ proteinuria discovered in A&E was not communicated to the ward.
(2) The Trust failed to communicate the significance of the persistently raised ESR and
CK to the patient and family.
(3) The Trust failed to send the GP a discharge summary or communicate to the surgery
the significance of the raised ESR and CK and the need for further monitoring.
(4) Despite the exceptionally high ESR, elevated CK of which no cause was found and
proteinuria, a diagnosis of cellulitis was preferred to that of a connective tissue disorder.
The opportunity to treat her SLE was missed due to failure to diagnose the condition,
whilst recognizing that diagnosis was hampered by her self discharge.
(5) Before discharge neither the patient nor the imminent self discharge were not known
to the consultant, who would have wished to be informed and would have sought further
investigations and communications
(6) Concerns (2) (3) and (5) above were not considered by the Serious Untoward
en Investigation by the Trust.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and ! believe that the
Trust has the power to take such action. The Trust is asked to consider these concerns
and whether, in the light of the inquest, that any, especially those it has not investigated
require further action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by Friday 4"" July 2014. |, 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.
If you require any further information or assis
case officer,
8 | COPIES and PUBLICATION
| have sentaco i roner and {o the following Interested
Persons: iia
have also sent it to the Department of Health, who may find it useful or of interest.
! am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both ina 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.
At Meg Lou
9 | [DATE] [SIGNED BY CORONER
i
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.
ABIOLA DOSUNMU DECEASED: INQUEST 16.04.14 RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Matters of Concern 1 The 3+ proteinuria discovered in A&E was not communicated to the ward. There is both a training issue and an issue regarding the use of electronic patient records at the Trust (raised as a recommended action in the SI report at item 1b). a) b) Training issue: Whilst it is not uncommon to have a trace/+ proteinuria on a urinalysis in a patient with a systemic infection, 3+ proteinuria on a urine dipstick should be recognised as abnormal and needing further investigation. In this case, the result was transcribed to the paper version of the medical admission proforma but not relayed to the inpatient team or noticed by them. The doctors involved in relaying this information no longer work at the Trust, but the Trust will refer the case to be included, as a reminder of the significance of this finding, in the formal teaching of Foundation doctors. The incident has already been shared at departmental governance meetings. Electronic records: The Trust supports the initiative from the Emergency Department (ED) to introduce point of care testing (POCT) to allow a faster turnaround of results and also an electronic transfer of results from ED to the ward. POCT has been planned for some time and subject to issues around assurance of the results and the IT interface, this should be in place by December 2014. In the interim, and in response to this incident, ED has revised the transfer checklist for patients being admitted to include results of tests done in ED. The checklist is appended to this report. The Trust failed to communicate the significance of the persistently raised ESR and CK to the patient and family The medical records (in particular the clinical noted dated 09.03.12 at 13.25 hours) suggest that the Trust communicated the significance of Abiola’s illness as it was understood at the time and did its best to dissuade her from leaving hospital. The Trust is satisfied that it acted appropriately by warning Abiola and her mother of the serious consequences of self-discharging. Nonetheless, with immediate effect consultants will be notified within 12 hours that their patient has discharged themselves from hospital to minimise the potential risk to the patient or others (see also paragraph 5 below). The Trust failed to send the GP a discharge summary or communicate to the surgery the significance of the raised ESR and CK and the need for further monitoring. a) Failure to send a discharge summary: A discharge summary should have been completed when Abiola self-discharged. As a resuit of this case, the Trust conducted an audit which showed that it is not consistent practice to issue discharge summaries for self-discharging patients. This issue was discussed with the Medical Director at the Trust's Serious Incident Committee on 26.06.14 and with immediate effect, discharge notifications will be produced for patients who self-discharge. b) Failure to communicate the significance of the raised ESR and CK and need for further monitoring to Abiola’s GP: The Trust contacted the GP by telephone informing the GP that Abiola had _ self-discharged, recommending oral antibiotics and stressing the importance of IV antibiotics and need for her to attend ED if her condition deteriorated. The Trust also notes that ED generated, and the GP received, a 4 page discharge summary which included (because it was generated on 9 March 2013) the abnormal results identified during Abiola’s admission. Had a discharge summary been produced by the inpatient team associated with her self-discharge, this would also have included these results and any recommendations about further investigations/monitoring. Please see 3(a) above for the action proposed by the Trust to address this concern. 4 Despite the exceptionally high ESR, elevated CK of which no cause was found and proteinuria, a diagnosis of cellulitis was preferred to that of a connective tissue disorder. The opportunity to treat her SLE was missed due to failure to diagnose the condition, whilst recognising that diagnosis was hampered by her self-discharge. Had the consultant been aware of the proteinuria at the post-take ward round, further tests would have been carried out. The actions that the Trust proposes to take in relation to this concern are set out in response to your first concern. 5 Before discharge neither the patient nor the imminent self-discharge were known to the consultant, who would have wished to be informed and would have sought further investigations and communications. It is not currently standard practice for Trust consultants to be informed of self- discharging patients. This issue was raised with the Medical Director at the Serious Incident Committee on 26.07.14 and it is now agreed that with immediate effect, consultants will be notified within 12 hours that their patient has discharged themselves from hospital, to minimise the potential risk to the patient or others. 6 Concerns (2), (3) and (5) above were not considered by the Serious Untoward Incident Investigation. (2) The SI report concluded that a working diagnosis of cellulitis was reasonable. On that basis, your second concern was not considered a concern for the reasons set out above. (3) A discharge summary was generated by ED and sent by email to Abiola’s GP. The SI report should have addressed the failure to send a second discharge summary to the GP. This has now been addressed under 3 above. (5) The SI did not identify this as a concern because it is not currently standard practice for Trust consultants to be informed of self-discharging patients. The Trust has now addressed this concern at paragraph 5 above.
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