Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0229, written 15 Jun 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jun 2015 |
|---|---|
| Reference | 2015-0229 |
| Deceased | Isaac Bahar |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 30B Assistant Coroners CATHARINE PALMER LL.B (HONS) MICHAEL KEEN KAREN HENDERSON, BSC,BM,MRCPI,FRCA GILVA D.J.TISSHAW, BA(LAW)HONS Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 CORONERS SOCIETY OF ENGLAND AND WALES ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. THIS REPORT IS BEING SENT TO: 1. ER Chief Executive, Brighton & Sussex University Hospitals NHS Trust 2. ER Chief Nurse, Brighton & Sussex University Hospitals NHS Trust 3, ER Ward Manager, Level 9a West Millennium Ward, Brighton & Sussex University Hospitals NHS Trust 1 CORONER | am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove 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 11" May 2015 | commenced an investigation into the death of Isaac Silas BAHAR. The investigation concluded at the end of the Inquest on 14" May 2015. The Narrative conclusion of the Jury Inquest was:- Mr. isaac BAHAR was a vulnerable man living at Hyman Fine House. He had a diagnosis of Bi-polar affective disorder. His mental health deteriorated requiring voluntary admission to Mill View Hospital. On the 10" of November, during the early hours Mr. Isaac BAHAR suffered an unwitnessed fall. At approximately 9:00am on the 10 November emergency services were called and Mr. BAHAR was admitted to The Royal Sussex County Hospital, where following examination it was determined that he had VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 sustained four fractured ribs and a traumatic pneumothorax for which he was treated. His medical records stated that he had stage four chronic kidney disease. As part of his treatment he was prescribed codeine by the locum doctors on duty at that time, which was in contravention of the national and local guidelines. The prescription was reviewed by the pharmacist the next day and was withdrawn. Mr. BAHAR appeared to stabilise but suddenly deteriorated on the 13™ of November. He was tended by the Medical Emergency Team at which stage the decision was taken to administer Naloxone to counter the toxic effects of codeine to which he partially responded. However, his condition continued to deteriorate rapidly, resulting in his death. It was later discovered by the pathologist that Mr. BAHAR had chronic obstructive pulmonary disease, which was deemed to be a contributory factor in his death. 4 CIRCUMSTANCES OF THE DEATH See Record of Inquest 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: Mr. Bahar was admitted to the Royal Sussex County Hospital on 10" November 2014 with pneumothorax due to fractured ribs. He was treated urgently and appropriately until his analgesia. He was a man with known Stage 4 Chronic Kidney Disease, yet in breach of the hospital's own policy and in breach of national guidance he was prescribed and given four doses of Codeine over 18 hours. Although this was stopped by the ward Pharmacist as soon as she was able to review his drug chart, Mr. Bahar collapsed with severe opiate/opioid toxicity 30 hours later and died just under three hours after the collapse. The Jury at his Inquest found this error to be one of the causes of his | death VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 The Codeine was directed by a locum surgical consultant and the fatal error was compounded when a locum junior doctor wrote up the Codeine in Mr. Bahar’s drug chart. Their locum status must be relevant and if the Trust employs locum staff they must satisfy themselves that those staff are aware of such guidance particularly in such a common scenario (elderly patient with Chronic Kidney Disease needing analgesia). The Trust is responsible for ensuring their patients are in safe hands. Senior nurses shouid also be aware of such common pitfalls. They would then be in a position when caring for their patients to pick up anomalies. This is a serious failing and must be urgently addressed. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3° September 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. 8 COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. Medical-Legal Services Manager, Brighton & Sussex University Hospitals NHS Trust, Chair, Brighton & Sussex University Hospitals NHS Trust Secretary of State for Health, Department of Health Simon Stevens, Chief Executive NHS England Nationai Patient Safety Agency Director of Public Health, Brighton & Hove Clinical Commissioning Group Director for Clinical Quality & Primary Care, Brighton & Hove Clinical Commissioning Group Oarwn N THE CORONER'S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 30B VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove Assistant Coroners Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 8. EE Acting Deputy Chief Pharmacist, Brighton & Sussex University Hospitals NHS Trust, 9. Specialist Clinical Pharmacist, Brighton & Sussex University Hospitals NHS Trust 10 SHO, ITU, Brighton & Sussex University Hospitals NHS Trust 11 RR Consultant intensivist, Chief of Safety & Quality, Brighton & Sussex University Hospitals NHS Trust | have also sent it to:- com = hy, Chief Executive, Sussex Partnership NHS Foundation Trust a | 3c Support Manager, Sussex Partnership NHS Trust _- Patient Safety Ombudsman, Brighton & Sussex University Hospitals NHS Trust Rone Who may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. VERONICA HAMILTON-DEELEY, LL.B. Her Majesty’s Senior Coroner for the City of Brighton & Hove THE CORONER’S OFFICE WOODVALE, LEWES ROAD BRIGHTON BN2 3QB Assistant Coroners Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 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. wl Date: 15" June 2015 Senior Coroner, Brighton
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.
AN Brighton and Sussex NHS| Gur refs MK565/KK 24 aug 208 | University Hospitals | 20 August 2015 | ____.------ == NHS Trust Headquarters Miss V Hamilton-Deeley The Royal Sussex County Hospital Her Majesty’s Senior Coroner Non For the City of Brighton & Hove BN2 SBE The Coroner's Office Woodvale, Lewes Road Tel: 01273 696955 Brighton BN2 3QB Dear Miss Hamilton-Deeley The Late Isaac Bahar, date of birth: 18.10.1941 NHS No: 623 012 4009 Thank you for your letter of 15th June 2015 and its enclosures, received on 19th June, and for drawing your concerns to our attention. We have not been able to identify any Trust member of staff called but we have ensured that the matron with responsibility for all the Level 9a wards has had sight of your report and an opportunity to reflect on the matters you have raised. We too have given careful consideration to your letter. As you know, we are always willing to review our practices in this Trust, in order to identify improvements which can be made in the light of experience. Mr Bahar was very unwell when he was admitted to the Royal Sussex County Hospital, and his prognosis was poor. However, we agree that it is wrong and unacceptable for any patient with chronic kidney disease, as suffered by Mr Bahar, to have codeine prescribed and administered to him. This was followed up with both the medical staff concerned - even though both happened to be locums, they had both worked continuously in the Trust for a considerable period; our investigations have not found any reason to believe that this acknowledged error arose from their locum status. They were both aware that codeine should not be prescribed in such circumstances. While the consultant was not able to recall the particular circumstances of the ward round in which his plan included prescribing codeine for Mr Bahar, the more junior doctor who actually wrote the prescription is clear that it was and remains her routine practice to check renal function by looking at the relevant test results before writing any such prescription. She was mortified to discover that on this occasion she must have failed to do so. She could only hypothesise, and apologise profoundly, that on this occasion there must have been some interruption or other distraction which made her overlook what she is well aware is a vital step before any such prescription is written. A ward pharmacist routinely reviews prescription charts, and when she found this inappropriate prescription she immediately discussed it at the time with the team and crossed off the prescription less than 24 hours after it had been written. With our partner oa brighton and sussex “e medical school The Trust’s lead pharmacist in patient safety carried out a detailed investigation of this matter. She found no evidence that there was a failure in knowledge or education, or any failure in selection or induction of locum staff, which caused or contributed to the medication being prescribed outside the Trust’s recommended analgesia guidance. The British National Formulary (BNF) makes it clear that codeine and other opioid analgesics should be avoided or used with caution at reduced doses in patients with renal impairment. Codeine was also used on the gastroenterology ward where Mr Bahar was a patient to help reduce diarrhea, a common symptom for gastroenterology patients. The lead pharmacist has confirmed that she would not expect nurses to be aware of the nuances of codeine metabolism in patients with renal impairment, and there was therefore no reason for the nurses administering the prescription to query this prescription before administering it. This incident, and the sad death of Mr Bahar, has been discussed in detail with both the general surgeons and the nursing team on Level 9a, as well as with the pharmacy team. As a direct result, the general surgeons decided that codeine should no longer be routinely available for them to prescribe. Discussions are continuing to seek a consensus as to whether the benefits of withdrawing codeine altogether from use within the Trust by other specialists would outweigh the associated disadvantages of such a step. Thank you once again for raising this concern with us. Please pass on our sincere condolences to Mr Bahar’s daughter and the family on their sad loss. Yours sincerely Matthew Kershaw Chief Executive Chief Nurse
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