Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0374, written 13 Aug 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Aug 2014 |
|---|---|
| Reference | 2014-0374 |
| 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 (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. James Scott
Chief Executive
Royal United Hospital
Combe Park
Bath
BA1 3NG
4 | CORONER
lam Maria Voisin, Senior Coroner, for the area of Avon
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.
[HYPERLINKS]
3 | INVESTIGATION and INQUEST
On 4" February 2014 | commenced an investigation into the death of Dorothy Joan
ROBINSON, aged 79. The investigation concluded at the end of the inquest on 11th
August 2014. The conclusion of the inquest was that the medical cause of death should
be recorded as
ta Respiratory failure
Ib Diffuse alveolar lung injury
Ic Busulphan treatment for myeloproliferative disorder
(thrombocythemia)
I Pulmonary emboli and infection
The conclusion | gave was accidental death contributed to by neglect.
4 | CIRCUMSTANCES OF THE DEATH
Mrs. Robinson had a disorder which required treatment and over the years she had at
times received Busulphan for this.
During 2006 she was seen by al with difficulties breathing. felt that
her symptoms may be due to the Busulphan and he wrote a letter to her consultant
advising that consideration should be given to using an alternative drug. Her consultant,
a said that at the time in 2006 she saw the letter and she wrote on it.
From 2006 to 2012 Mrs. Robinson did not receive Busulphan.
In tate 2012 she was again given Busulphan by EEE who said that in 2012 she
had no recollection of the letter and if she had she would not have prescribed
Busulphan.
In December 2013 Mrs. Robinson’s breathlessness became a concern, she developed
pneumonitis due to the Busulphan she was admitted to hospital on 18'" January severely
unwell and sadly died on 27" January 2014.
It is clear that the death was due to an adverse drug reaction causing the pneuomonitis
it also appeared that there was a failure to remember the previous intolerance recorded
in the records by the consultant when re-prescribing Busulphan or to consider why the
drug had been previously stopped before re-prescribing it.
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. —
During the inquest | heard evidence that there remains a risk of a prescribing error
despite the steps taken by RUH to date. | have been advised that there is only one way
to help prevent this and that is through the electronic prescribing system referred to in
the Action Plan to the Root Case Analysis. | was not told an exact date when the system
will be introduced only that there was an understanding that it may take up to two years.
| would like to receive reassurance from the RUH as to the exact steps that are being
taken in relation to installing this system or indeed any other system which can help
prevent a prescription error.
| was advised that the millennium system is not proposed to be used in this way
Therefore in summary please advise of the steps planned to be taken to prevent a
prescription error across the whole of the Trust in all areas of medicine due to a previous
intolerance/reaction/allergy.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
{AND/OR 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 Friday 10 October 2014 . |, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, seiting 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
Persons — the family.
| 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.
13/8/14 M. E. Voisin eae
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.
/RUH| Royal United Hospital Bath INHS| NHS Trust Directors’ Office 45th October 2014 Royal United Hospital Bath NHS Trust Combe Park 40 ge" ange Bath Po ute Zak BA1 3NG ME Voisin a Coroner's Court 2 The Courthouse www. ruh.nhs.uk Old Weston Road Flax Bourton BS48 1UL Dear Ma'am Coroners Regulation 28 Report — Dorothy Joan Robinson Recommendation 4 of the investigation report written by HE suggests the introduction of a Trust-wide electronic prescribing system that readily makes available information about previous adverse drug reactions at the time of prescribing and dispensing of medications. Further, that the system could mandate completion of adverse drug reaction information before a prescription is accepted on the system. In the ensuing action time line the report notes that this is currently being assessed, but implementation is likely to take at least two years. The Trust continues to expand its use of information technology in support of safer clinical care and has recently committed to investing £18m in a replacement patient administration system, the foundation stone from which we can fully develop electronic clinical systems. Currently there is limited experience of e-prescribing systems in the NHS across the country. What experience hospitals have had has highlighted the need for a cautious approach with time spent testing and refining to avoid unintended consequences. The RUH Information Technology and clinical teams have close working relationships with other hospitals that are implementing e-prescribing and continue to learn from those leading this improvement. Of particular note is our work with the Oxford University Hospitals NHS Trust who use the same base system as the RUH and are just in the process of a phased roll out of e-prescribing. Pending the development of e-prescribing at the RUH, which may well take more than two years to be fully implemented, we have strengthened processes to mitigate the risk of a drug being administered to a patient who is known to be intolerant of it. Presently, our non-electronic prescribing systems incorporate the need to record such an intolerance. Patients attend the Royal United Hospital as in-patients, out-patients and as day case patients. If patients require a medicine in any of these settings, the pharmacy will not supply that medicine against a prescription unless the allergy / adverse reaction box has been completed on the medication chart. Through internal reminders and education we continue to emphasise this absolute rule. In addition, nurses check the allergy status of in- patients before administration of medicines. Chairman, Brian Stables Chief Executive, James Scott H ea | th care yo u can Tru st in specific specialties, such as Oncology and Haematology there is an electronic prescribing system that mandates the entry of an allergy / adverse reaction at the point of prescribing. This system is called ARIA and is referred to in the investigation report. Investment has been made to develop ARIA to ensure that it covers all out-patients and in- patients receiving the complex medicines regimens prescribed in Oncology and Haematology. This will take a further 12 — 18 months to complete. An electronic prescribing module for patients being discharged with medication from the RUH has been developed and will be launched in March 2015. An earlier system was tested Trust wide in 2013 but required revision to capture all the safety features, an example of how testing and refining of e-prescribing is essential to avoid solving one problem whilst creating another. This system will also mandate the entry of allergies/adverse reactions in the discharge letter that goes to GPs. Currently this is done manually if an adverse reaction occurs in hospital. The transition from paper-based health records to electronic systems at the RUH is a gradual and lengthy process. Any change of this enormity can present some risks, but these risks are managed through the Medical Records Users Group, a body that is led by one of the Trust’s most senior clinicians and which works closely with the Clinical Informatics Group and Information Technology teams. No system, whether electronic or not, can ever reduce the risk of prescribing a medicine for a patient who is intolerant of it to zero. | hope | have demonstrated to you, though, the actions we have taken to mitigate that risk as much as we can. If you would like to discuss the contents of this letter further, both myself and | Medical Director would be happy to meet with you. Yours sincerely
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