Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0489, written 11 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Nov 2014 |
|---|---|
| Reference | 2014-0489 |
| Deceased | Beryl Walters |
| Coroner | Andrew Thompson |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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. National Institute for Clinical Excellence 2. College of Emergency Medicine 1 CORONER I am Dr. Andrew Thompson, Assistant Coroner, for the coroner area of Black Country. 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 On 27 June 2014, I commenced an investigation into the death of Beryl WALTERS. The investigation concluded at the end of the inquest on 11 November 2014. The conclusion of the inquest was the deceased died from 1a. Myocardial Infarction and mitral valve disease; 1b. Coronary artery thrombosis; 1c. Coronary artery atherosclerosis; 2. Cyclizine administration. My conclusion was Natural Causes 4 CIRCUMSTANCES OF THE DEATH 1. Mrs Walters presented at A&E with an atypical history of chest pain 2. An ECG showed a posterior Myocardial Infarction. 3. According to the local pathway she was given an antiemetic (Ccyclizine) as she reported feeling sick. The pathway did not at that time specify which anti-emetic should be given, and during the evidence heard it transpired that in the hospital concerned, Cyclizine was widely used in these circumstances. 4. Very shortly after the administration of Cyclizine Mrs Walters went very hypotensive and tachycardic, and then suffered a Cardiac Arrest from which she could not be resuscitated. 5. At Post Mortem, there was evidence of severe Right Coronary Artery occlusion by atheroma, with appearances consistent with early infarction in the posterolateral part of the left ventricular wall. 6. The reporting pathologist drew my attention to the existence of a paper from 2006 (attached) the conclusion of which was “Cyclizine should be avoided in patients with acute coronary events”. 7. The hospital concerned has now revised their pathway in the light of these circumstances to advise the use of Metoclopramide as the first line anti-emetic in patients with acute coronary events. 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 [IL1: PROTECT] The MATTERS OF CONCERN are as follows. – (1) The British National Formulary states in the cautions part of the section on Cyclizine “severe heart failure; may counteract haemodynamic benefits of opioids;…” (2) The paper attached, whilst itself drawing the reader’s attention to the possible non- transferability of the findings to the emergency department, and the limited group of patients the original 1988 study was based on, makes a recommendation not to use Cyclizine in these circumstances. (3) The availability of an alternative antiemetic, Metoclopramide, which does not appear to share the same cardiac risk profile, would seem to suggest that the use of Cyclizine is an unnecessary risk in these circumstances. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 6 January 2015. 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 and to the following Interested Persons, Mrs Walter’s family, Sandwell and West Birmingham Hospital Trust. 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 11 November 2014 2 [IL1: PROTECT]
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