Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0264, written 9 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jul 2015 |
|---|---|
| Reference | 2015-0264 |
| Deceased | Michael George |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | South London and Maudsley NHS Foundation Trust |
| 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 THIS REPORT IS BEING SENT TO: Dr Matthew Patrick, Chief Executive, South London and Maudsley Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham BR3 3BX CORONER Tam Dr Andrew Harris, Senior Coroner, London Inner South 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. i INQUEST On 9th December 2011, ! opened an inquest into the death of: Michael George, who died on 7th December 2011, at 02.40 a.m. in King’s College Hospital, Case Ref: 03102-2011. It was concluded before a jury on 12th June 2015. The court found that the medical cause of death was 1a Multi-organ failure 1b Hyperosmolar hyperglycaemic state, in schizophrenic treated with Olanzapine. CIRCUMSTANCES OF THE DEATH The narrative conclusion included these matters in the record: a) The Maudsley Hospital failed to address the risk of Mr George developing diabetes from the long tern use of Olanzapine and did not check his urine or blood sugar prior to 06/12/11. b) At 09.30 on 06/12/11 Mr George complained of being weak, tired, having blurred vision and making frequent trips to the lavatory and asked to see a doctor. At a case review meeting held at 11.00 a.m. on 06/11/12 the results of a urine test, which showed the presence of blood and glucose, a physician was not consulted, leading to an inadequate care plan.... ¢) At 18.30 when the laboratory .. phoned through the blood glucose results... the precise measurement of 53.7 mm/! was misunderstood by staff, who did not appreciate that [his] condition was life threatening. As a result.... decisions regarding ..... transfer to A&E had an insufficient level of urgency. [NB: There was no entry of 53.7 in records] d) From 18.30 once these glucose results were received, the Maudsley Hospital attempted to transfer Mr George to A&E. However the time delay between 18.30 and 21.20, when he eventually arrived at A&E had a significant impact on his chances of survival because it delayed the administration of sufficient levels of fluid to aid his rehydration. e) The referral information from the Maudsley did not contain critical information about Mr George’s background and current condition to enable A&E to appreciate the urgency of his condition and the difficulty of managing a patient who was refusing treatment. It should be added that it was reported that for a large part, but not all of his hospital admission, he had capacity and exercised it to refuse investigations and transfer. i 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. Two previous PFD reports on the care of physical illness in mental health wards run by the Maudsley Hospital had been made by this court: One (2654-11) was sent in September 2014 concerning a death in October 2011. It reported the opinion of an expert that there needed to be domiciliary visits by consultant physicians, as would occur in a District General Hospital. Another (0883-13) following a death from diabetic ketoacidosis, reported the lack of mandatory and regular glucose testing whilst on anti-psychotic medication. This was sent in January 2015 reporting on a death in April 2013. The MATTERS OF CONCERN are as follows. — Expert evidence was heard that: (1) The management spokesperson on the Action Plan at the inquest was unaware that the Trust had received these two court Regulation 28 reports, suggesting that senior management attached insufficient importance to them and the issue of physical health care of mentally ill patients. (2) Although there was now systematic recording of urine and blood glucose of patients on antipsychotics on the wards, the audit conducted and presented in court showed a number of patients who had refused these tests, but not demonstrated whether in subsequent weeks testing was conducted or whether these same patients, like Mr George, never had their glucose measured, noting that urine measurement was non invasive, and had an appropriate care plan to address these risks. (3) The Trust response to 2654-11 in September 2014 was that a research bid was being mounted and discussions held with commissioners and Kings College Hospital (KCH). Progress on this was not provided to the court and there had apparently not been action to reduce risks of deaths by ensuring there were domiciliary visits from consultant physicians at KCH (which is across the road from the Maudsley) to mental health wards, as reported to the Trust in 2014. The need to implement such a service was again reiterated by a different expert in this inquest. It is inferred from the expert opinion that failure to do so would mean that patients in SLAM in-patient units would be more at risk than those mental health patients in a district general hospital. (4) Whilst there had been individual learning and changes in training and note keeping and recording, it was unclear whether, in the absence of consultant physician advice, that the serious untoward incident investigation conclusion on urgent transfer would be heeded. It advised that there should have been immediate action to call an ambulance to effect transfer, despite lack of consent, when the blood results were known. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe that the South London & Maudsley NHS Foundation Trust has 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 September 2™, 2045. |, the coroner, may extend the period. a 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. If you require any further information or assistance about the case, please contact the case officer, COPIES and PUBLICATION (experts who gave opinions in the inquest), Southwark Clinical Commissioning Group, the Royal College of Psychiatrists, and the Secretary of State for Health. | 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. Lha’ 'y report to the following Interested Besson and sisters). | have also sent a copy t and ii [DATE] [SIGNED BY CORONER I fdy dors < | apologize for the delay in sending this report, which relates 6’ staff illness.
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.
South London and Maudsley NHS Foundation Trust NHS Medical Director's Office Trust Headquarters Administration Building Maudsley Hospital Denmark Hill London SE5 8AZ Telephone: 020 3228 2415 Case Ref: (cid:9) 03102-2011 Vt September 2015 Dr Andrew Harris Senior Coroner Southwark County Court 1 Tennis Street London SE1 1YD Dear Dr Harris Re: (cid:9) Michael George, who died on the 7th December 2011 I write in response to the Regulation 28 Report to Prevent Future Death in the case of Michael George. Expert evidence was heard that: 1) The management spokesperson on the Action Plan at the inquest was unaware the Trust had r(ceived these two court Regulation 28 reports, suggesting that senior management attached insufficient importance to them and the issue ofphysical health care of mentally ill patients. 2) Although there was now systematic recording of urine and blood glucose of patients on anti-psychotics on the wards, the audit conducted and presented in court showed a number of patients who had refused these tests, but not demonstrated whether in subsequent weeks testing was conducted or whether these same patients, like Mr George, never had their glucose measured, noting that urine measurement was non-invasive, and had an appropriate care plan to address these risks. 3) The Trust responses to 2654-11 in September 2014 was that a research bid was being mounted and discussions held with commissioners and Kings College Hospital (KCH). Progress on this was not provided to the court and there had apparently not been action to reduce risks of deaths by ensuring there was domiciliary visits from consultant physicians at KCH (which is across the road from the Maudsley) to mental health wards, as reported to the Trust in 2014. The need to implement such a service was again reiterated by a different expert in this inquest. It is inferred from the expert opinion that A.Harris - Sou. CC - M. George - 07.12.11 - 01.09.15 www.slam.nhs.uk Page I 1 failure to do so would mean that patients in SLAM in-patient units would be more at risk that those mental health patients in a district general hospital. 4) Whilst there had been individual learning and changes in training and note keeping and recording, it was unclear whether, in the absence of consultant physician advice, that the serious untoward incident investigation conclusion on urgent transfer would be heeded. It advised that there should have been immediate action to call an ambulance to effect transfer, despite lack of escort, when the blood results were known. The Trust has paid particular attention to the physical health care of our patients and those with diabetes in particular. There are a number of initiatives which we hope will help prevent future deaths from the complication of diabetes on our wards: 1. The Trust has established a Physical Health Committee chaired by two consultant . The committee has been , Consultant Diabetologist in improving the psychiatrists, working closely with management of Diabetes Mellitus on our wards. and 2. e has done work with the Maudsley in the past to help provide a framework for the management of non-urgent diabetes as a Maudsley inpatient. She is in the process of revising this older protocol. 3. The MEWs (Modified Early Warning scores, soon to change to NEWS, National Early Warning scores) have been rolled out and are improving the ability of mental health nurses to pick up deteriorating patients. 4. , Consultant Diabetologist, Kings College Hospital (KCH) last year to produce the attached protocol for the management of hyperglycaemia on our wards. (Appendix I) , Core Trainee 3 (CT3), SLaM linked with 5. In relation to the previous recommendation of Inreach medicine into the system, the Trust collaborated with KCH to put in a bid for a Medical Liaison Team to consult on the medical management of our inpatients. After repeated revisions, this was turned down. This was unfortunate as we had clearly demonstrated the need as evidenced in Appendix II, where we show that over 10% of our admissions are medically unstable enough to require a night in a general hospital as part of their SLAM inpatient stay. However, to my knowledge, no Mental Health Trusts have Inreach medical care on their general psychiatry wards, although many forensic units have GPs who visit (in keeping with the long length of stay). We plan tp continue to lobby for resources to establish such a service. 6. We have linked with KCH to continue to improve access to care and demonstrated in a pilot study how this affects length of stay in the acute hospital - an indirect indicator of medical need. (Appendix III) I also attach the pathway for rapid access to medical care from the Maudsley site. (Appendix IV) and 7. This is a keen area of interest for the Trust to develop, nationally as well as locally. Dr an from the Trust are members of a National Confidential Enquiry into Patient Outcome and Death group (NCEPOD) looking at the care of people with significant mental illness in the acute hospital. This derives from the Trust work with Kings, in that the chair and proposer of the topic is , Acute Medical Consultant in KCH, whom we have worked with closely on this problem. AHarris— Sou. CC —M. George— 07.12.11 - 01.09.15 www.slam.nhs.uk Page 12 8. The lack of appreciation of the urgency of the high glucose is important, but not surprising, given the minimal medical exposure in current nursing training. We believe there is a need for more general nursing as part of the RN'[N course, that would be potentially very constructive. 9. The psychosis physical Health Strategy (Appendix V) does suggest monthly full blood fasting blood glucose (FBG) or random blood glucose (RBG) plus glycolated haemoglobin HBA1c for the first 3 months on clozapine and olanzapine and we are in the process of develop protocols for this. This is a local target and not in the 2014 NICE guidelines. (Appendix VI) 10. CQUINS (commissioning for quality and innovation) have optimised the requesting of tests on the wards but the management of patients refusing tests is very difficult. It is possible to take glucose under restraint under the MHA. The MCA may be used but, restraint for bloods is technically difficult and if someone has a treatment responsive illness, in the absence of an acute deterioration, people often wait for their mental health to settle and try again once, they regain capacity. If someone is refusing bloods, it is rare for them to agree to urine testing - urine is usually more difficult to get than blood. However with respect to sugar, a BM Stix under restraint is feasible - though not pleasant. 11. The Trust is considering adding the Glasgow Anti-psychotic Side-effects Scale (GASS) to our electronic patient record. We have also adapted the use of the GASS for use with clozapine (which we have shown to have a high rate of diabetes). This looks specifically for symptoms suggestive of rising blood glucose. (Appendix VII) 12. SLaM is investing a considerable amount of effort to this area and is liaising widely to generate solutions, which we disseminate locally and internationally. (Appendix VIII) 13. We are as an organisation hugely aware of the need for joint approaches to solve these problems. With this in mind, our CEO, Dr Mathew Patrick, has set up a working group as part of the London Strategic Clinical Network, which he co-chairs, to promote the generation of cross-system solutions. I hope this letter and its attachments are a testament to the issues which were raised and our continued efforts to improving our services. Kind regar Medical Dir Enc. A.Harris - Sou. CC —M. George— 07.12.11 - 01.09.15 www.slam.nhs.uk 13
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