Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0024, written 27 Jan 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Jan 2015 |
|---|---|
| Reference | 2015-0024 |
| Deceased | Rafel Delezuch |
| Coroner | Martin Gotheridge |
| Coroner area | Leicester City & South Leicestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals of Leicester NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
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. Mr John Adler, The Chief Executive, Leicester University Hospitals NHS Trust
1
CORONER
I am Martin Gotheridge, Assistant Coroner, for the coroner area of Leicester City and South
Leicestershire
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 23 August 2012 I commenced an investigation into the death of Rafal Delezuch. The
investigation concluded at the end of the inquest on 23rd January 2015. The conclusion of
the inquest was that Mr. Delezuch died from Amphetamine induced delirium in association
with prolonged struggle.
4
CIRCUMSTANCES OF THE DEATH
Early in the morning, from about 06.00 onward, the patient was seen to have been acting in
a bizarre manner in the Highfields area of Leicester, including knocking on doors and
exhibiting symptoms of paranoia. The police were called. The patient voluntarily got into the
back seat of a police car, but then became agitated and the officer attempted (without
success) to subdue him by use of his captor spray. 3 other officers eventually attended the
scene and the patient was restrained and detained under S.136 M.H.A. and taken to L.R.I.
in the back of a police van.
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) Although the Trust had a policy for Restraint for dealing with aggressive patients, it
became clear from the witnesses from the Trust who gave evidence, that many of the staff
in the Emergency Department (including the Senior Registrar in charge of the case) were
either wholly unaware of the Policy or unaware of, and had no training in, the application of
the policy.
1
(2) It also became clear that the Senior Registrar was not familiar with the dangers of
prolonged restraint of a patient in the prone (face-down) position
(3) When it was decided that the patient was in need of rapid tranquilisation then:
a) A supply of Lorazapam from the manufacturer was apparently not available and no
policy appeared to have been devised for the priority use of any limited supply of
Lorazapam within the Trust and there was no awareness amongst the clinicians of the
availability of alternative medications
b)The possibility of a licensed product or of the alternative of Promethazine does not
appear to have been pursued. The importance of quick-acting drugs, for the purpose of
rapid tranquilisation did not appear to have been fully appreciated.
(4) Although the NICE guidelines were printed off and consulted in dealing with the rapid
tranquilisation, a reference there to the fact that diazepam was “not recommended” was
overlooked.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action by way of appropriate policies, and above
all ensuring training so that all members of the clinical staff are aware of those policies.
Also a review of medecines that should be maintained in ED for use when Rapid
tranquilisation is necessary may help to avoid future deaths.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 24th March 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 Bhatt Murphy (solicitors for the family) and to
Weightmans (solicitors for the Police)
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
[DATE] 27th March 2015
2
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.
University Hospitals of Leicester NHS) NHS Trust Direct Line: Fax No: E'Mail: Your Ref: Our Ref: 24 March 2015 Mrs C Mason HM Coroner The Coroner's Court, Town Hall, Town Hall Square, Leicester LE1 9BG Dear Mrs Mason Re: Rafal Delezuch | write further to the Regulation 28 report sent to us on 29 January 2015 by your Assistant Coroner, Mr M Gotheridge and am now in a position to respond. | note that the matters of concern are as follows:- 1. Many of staff in the emergency department were unaware of and had no training in the application of the Trust's Restraint Policy. 2. The Senior Registrar was not familiar with the dangers of prolonged restraint in the prone position. 3. When it was decided that Mr Delezuch needed rapid tranquilisation, clinicians a) were not aware of the availability of alternative medication lorazapam b) the importance of quick acting drugs, did not appear to be fully appreciated. 4. The reference in the NICE Guidelines to diazepam being ‘not recommended’ was overlooked. You have suggested that all clinical staff be made aware of these policies and also that a review of medicines that should be maintained in our Emergency Department for use when rapid tranquilisation is necessary. | am pleased to be able to report that since the inquest, the Clinical Director for Emergency and Specialist Medicine, has met with the Head of Service for the Emergency Department and our Chief Pharmacist and will be undertaking action to strengthen and improve our processes. This case has been discussed at an Emergency Departmental meeting and has been reported to our Adverse Events University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary Website: www.leicesterhospitals.nhs.net Chairman; Mr Karamjit Singh Chief Executive: Mr John Adler Committee which is chaired by a senior clinical manager and will be discussed at our next Executive Quality Board which is chaired by myself. The Clinical Director and Head of Service for the Emergency Department between them have ensured that all clinical staff in the Emergency Department are aware of the Trust's Restraint Policy and of the particular dangers of prolonged restraint in the prone position. In addition, our Chief Pharmacist has met with the Leicestershire Partnership Trust to develop a shared rapid tranquilisation guideline; our Clinical Director will ensure that this guideline is in place by the end of May 2015. This Guideline will also deal with appropriate consideration of the relevant NICE Guidelines. Additionally working alongside an external organisation we are undertaking work to improve the accessibility of our Trust Policy and Guidelines generally. We expect that this work to improve the accessibility of our Policy and Guideline Library and is expected to be completed by the end of June 2015. | trust that this response assures you that we take these matters seriously and if you have any further concerns please do not hesitate to contact me. Kind regards Yours sincerely John Adier Chief Executive University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary Website: www. leicesterhospitals.nhs.net Chairman: Mr Karamjit Singh Chief Executive: Mr John Adler
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