Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0194, written 13 May 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 May 2015 |
|---|---|
| Reference | 2015-0194 |
| Deceased | Hana Elhamid |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Alcohol, drug and medication 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.
: ' North London Coroners Court, Her Majesty's Coroner for the 29 Wood Street, Northern District of Greater London —=Barnet ENS 4BE (Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Department of Health Richmond House 79 Whitehall / London SW1A 2NS 1 | CORONER | am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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. 3 | INVESTIGATION and INQUEST On the 9" June 2014 | opened an investigation touching the death of Hana Aisha Abd Elhamid , 25 years old. The inquest concluded on the 7" May 2015. The conclusion of the inquest was “Narrative”, the medical case of death was 1a Respiratory failure 1b Tracheal Stenosis complicating laryngotracheal injury sustained during self-extubation during treatment for a diabetic coma 4 | CIRCUMSTANCES OF THE DEATH Miss Abd Elhamid was a patient being treated for a mental health condition and it became necessary to treat her condition with Clozapine. It is likely that the diabetes was a complication of the use of Clozapine and routine fasting blood tests were not carried out which was a serious failure. It is likely that the diabetes had been developing for some time before Miss Abd Elhamid became seriously unwell whilst on a home visit. Miss Abd Elhamid was taken to the hospital on the 13" November 2012. There was a medical need to intubate Miss Abd Elhamid and during the process of waking Miss Abd Elhamid extubated herself. Although this is not unusual in these circumstances in this case the result was damage to the airway. Many attempts were made to treat Miss Abd Elhamid at a specialist hospital where a tracheal stent was fitted. Miss Abd Elhamid became unwell with breathing difficulties and was admitted to hospital on the 4" June 2014. A decision was taken to attempt to treat Miss Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) Abd Elhamid which encountered such difficulties due to the narrowed airway that Miss Abd Elhamid died. There was an opportunity to test for blood sugar which is likely to have demonstrated the presence of diabetes at a time where the diabetes would have been amenable to treatment. There was therefore an opportunity to render care which if taken would have prevented the death. 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. — that this patient developed diabetes whilst on long term Clozapine treatment and that routine blood tests for sugar in the blood are likely to have prevented events, the need for intubation during treatment for a diabetic coma with resultant trachea injury following self -extubation, that directly led to the patients death 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 Wednesday 8” July 2015. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- Representatives of iy Glen Care oyal Free London Foundation Trust Barnet Hospital. Barnet Enfield and Haringey Mental Health Trust. lam 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 responge, alygut the release or the publication of your response by the Chief Coroner. 13” May 20
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.
RGR Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of H ealth Richmond House 79 Whitehalf London SW1A 2NS POC3000 946771 Tel: 020 7210 4850 Mr A. Walker Senior Coroner North London Coroner's Court. 29 Wood Street Barnet ENS 4BE 16 JUL 2015 Vern Wo Valles , Thank you for your letter of 13 May 2015 following the inquest into the death of Hana Elhamid. I was very sorry to hear of Miss Elhamid’s death and wish to extend my sincere condolences to her family. Although the medical cause of Miss Elhamid’s death in 2014 was respiratory failure, you consider that if she had been diagnosed as having diabetes in 2012, then none of the other medical events, which ultimately led to her death, would have occurred. You point out that there was an opportunity to test Miss Elhamid for blood sugar levels while she was in the care of the London Treatment and Rehabilitation Centre (LTRC), which would have revealed the diabetes at a time when it could have been treated and managed. You raise the following concerns: e that the patient developed diabetes when on long term Clozapine treatment e that routine blood tests for sugar in the blood are likely to have prevented events that led directly to Miss Elhamid’s death. I expect any patient in a mental health setting to receive all appropriate care and treatment for mental and physical health conditions. Barnet, Enfield and Haringey Mental Health Trust (BEHMHT) confirm that it was recommended that Miss Elhamid start a trial of Clozapine in February 2009. In April 2009, Miss Elhamid was transferred to the Ashwood Centre in Croydon , (part of the LTRC) where, I am told, she was not prepared to have blood tests taken and so the trial was not initiated. Miss Elhamid did not begin taking Clozapine until May 2012, whilst in the care of LTRC. I understand that LTRC could not provide you with records detailing blood glucose tests taken between May 2012 and November 2012 as no such tests had been carried out. BEHMHT conducted a root cause analysis investigation following the death, which examined whether the clinical care and treatment at BEHMHT was to an acceptable standard and in accordance with policies and procedures. You may wish to contact BEHMHT directly for further background information about this investigation and its outcome. Clear guidelines, concerning the monitoring of patients who are using antipsychotic medication such as Clozapine, exist and are published by NHS Choices and the National Institute of Health and Care Excellence (NICE). The raised risk of developing diabetes when on Clozapine treatment is known. In addition, NICE’s clinical guideline, Psychosis and schizophrenia in adults: treatment and management (CG 178) advises that blood glucose is checked before starting antipsychotic medication; that the secondary care Mental Health service should continue to monitor this for at least 12 months or later if the person has not stabilised; and that GPs should continue to monitor this when responsibility is transferred to them. Your report has also been shared with NHS England. NHS England is currently working with the Royal College of Psychiatrists and the Prescribing Observatory for Mental Health to investigate patient safety incidents associated with Clozapine. Patient monitoring is included within the scope of this work. Should compelling evidence of system failures be found, then NHS England would support work to improve management and minimise harm. I hope that you find this reply helpful and I am grateful to you for bringing the circumstances of Miss Elhamid’s death to my attention. Yn sircunt, rt ie ALISTAIR BURT
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