Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0381, written 17 Sep 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Sep 2015 |
|---|---|
| Reference | 2015-0381 |
| Deceased | Lee Bates |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
H M Coroner, London Inner South
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT !S BEING SENT TO:
1. Mr Saleem Asaria, Chief Executive Officer, The Cambian Group, 4" Floor,
erent Building, Hammersmith, Embankment, Chancellors Road, London W6
2. Mr Ron Kerr CBE, Chief Executive, Guy’s & St Thomas NHS Foundation Trust,
Westminster Bridge Road, London SE1 7EH
CORONER
| am 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.
INQUEST
On 3rd April 2014, | opened an inquest into the death of:
Lee Mark Anthony Bates, who died on 24th February 2014, at 01.1
hours, in Cambian Churchill London Clinic, al
It was concluded before a jury on 19th August 2015. The jury found that the medical
cause of death was:
1a Zopiclone and Benzodiazepine usage and obstructive sleep apnoea.
ll Severe obesity
and concluded that the death was an accident.
CIRCUMSTANCES OF THE DEATH
The jury found that:
“At 0.18...... Mr Bates died. The cessation of breath resulted in the CPAP machine
stopping. His death was due to a potentially fatal overdose of Zopiclone being ingested
in conjunction with benzodiazepines [Note: some were prescribed; some acquired] whilst
under one to one eyesight observation. No evidence was heard to indicate that staff
were sufficiently trained in the implementation of one to one eyesight observation policy.
Contributory factors to his death were sleep apnoea and obesity.”
Technical evidence was admitted confirming that the Continuous Positive Airways
Pressure (CPAP) machine delivered a prescribed pressure of air for sleep apnoea and
was not a method of providing oxygen or a life support machine, but there was an event
between 01.11 and 01.18. An engineer’s evidence was that the machine stopped at this
time, but this did not necessarily indicate absence of life as it could be due to one of
three reasons:
a) it was manually switched off . There was no evidence this had occurred. The machine
was managed by Mr Bates and not by the staff, but he was reported to have gone to bed
with the mask on his face.
b) the mask has been removed . The mask was witnessed to be on his face at 04.00
and 04.30 when the alarm was raised and CPR begun.
c) there was a leak from mask e.g. from poor facial hygiene, beard or break in mask.
The CPAP mask and venting were inspected and were in good condition, with no
blockage. The strap was fine and they fitted together properly. il gave
evidence that his small beard would be insufficient to cause the cessation of recording.
it was reported to the court that hourly observation was noted at 02.00 and 03.00. A
nurse gave evidence that she heard his breathing and saw his diaphragm going up and
down between 03.00 and 04.00. She and a support worker turned the light on at 04.00
and saw that Mr Bates was moving indicating he was breathing. At 04.30 the support
worker, observing from 14 feet away, instinctively felt something was wrong, noting he
no longer heard the background noise of the CPAP machine.
The Cambian Churchill reported that since the death there had been a reissue of the
observation policy, raised awareness of what it required and staff training.
who heads the sleep apnoea clinic which Mr Bates attended in
GSTT said that his overnight oximetry showed he had falls in oxygen levels of 100 per
hour, which were reduced to 2.5 per hour with the use of CPAP. He had therefore very
severe sleep apnoea, which was dramatically controlled by use of CPAP.
said that there is cumulative damage if the CPAP machine was not Used.
night it would reduce, but not eliminate the risk of death.
He said that Lorazepam theoretically has an effect on breathing. It should not be used in
untreated sleep apnoea. If used when CPAP was on, it had the potential to make the
sleep apnoea worse. The impact is statistically small, but in more severe sleep apnoea
is more likely to have an effect. He was at a loss to predict if its prescription had
contributed to death. He said that the consultant neurologist who saw him in the sleep
clinic did not know he was to be prescribed Haloperidol or Lorazepam. He gave no
warning or information about risks of prescribing. The professor said that Lorazepam
should be avoided, but did not criticize its prescription, and would have expected the
psychiatrists to contact the sleep clinic if they needed advice. If Mr Bates had to have
sedative drugs, and was in his hospita| ATS cic that he would be monitored
with an oximeter.
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. —
The court heard that neither the psychiatrists sought advice from the sleep apnoea clinic
nor did the clinic inform the psychiatrists of the importance of using CPAP, the risks of
not doing so and the ri ive medication especially if not using it and the
desirability of cane lll of the hospital, said that there was no
guidance from GSTT about the use of the CPAP machine, of which psychiatric staff
would not be familiar. He presumed that none of the psychiatrists sought guidance about
medication, observation or use of the machine in a patient with severe sleep apnoea, as
they did not see the need. He expected that the sleep clinic would provide any advice
that psychiatrists needed in managing the OSA in a psychiatric unit.
| consultant psychiatrist at Cambian, acknowledged that there were risks of
death to people with severe OSA given drugs and then not taking CPAP. Physical health
care needs were advised by GPs. He said that psychiatric staff did not know about the
importance of CPAP, nor whether introduction of a drug required monitoring. There is
the facility to use pulse oximetry in the hospital, but the implications, if it were to be used
in all OSA patients, would need to be considered. There are many OSA patients in
Cambian.
It is clear that there is an on going risk of avoidable death in patients with OSA in
Cambian Churchill hospital (especially if severe and associated with morbid obesity),
Although this risk is reduced by use of CPAP machine and increased by use of sedative
drugs, and may be mitigated by use of oximetry, such measures require dialogue
between specialist physicians and psychiatrists and might require special provision for
monitoring of patients that are high risk and require sedation. Neither hospital has
addressed how this dialogue is to be instigated when required, nor how these risks
shouid be addressed; reliance on GP advice seeming to be insufficient.
2
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe that the
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 Thursday 12" November 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.
If you require any further information or assistance about the case, please contact the
COPIES and PUBLICATION
| have sent a copy of my report to the following Interested Persons:
{NOK}, Professor of Sleep Medicine Guy's & St Thomas’ Hospital,
Consultant Psychiatrist at Cambian Churchill, | have also sent a copy
to EE Chief Executive South London & Maudsley Trust,
Cambian Commissioner il Chair of Joint Commissioning Panel
for Mental Health Services, i EER oyal College of Psychiatrists
and Rt. Hon Jeremy Hunt 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.
[DATE] [SIGNED BY CORONER]
(7 vA Co (iS fl
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.
aw . “ Cambian hu A ka Dr Andrew Harris YVease toeale Senior Coroner Gad & to Nok Inner South London Coroner's Court 1 Tennis Street A fi London AE1 1YD _— . _ . Pek 20! November 2015 Dear Dr. Harris, Inquest into the death of Lee Bates Response to a Regulation 28 Report I write in response to your Regulation 28 Report dated 17" September 2015. I am grateful to you for bringing these matters to my attention as the Cambian Group takes all patient safety issues very seriously, particularly where there may be lessons to be learnt more widely. The death of Lee Bates was obviously an extremely sad event and my sympathy goes to everyone who knew him, especially his family. From the perspective of the Cambian Group, there are lessons to be learnt, and we will ensure that these are appropriately addressed. Your Report raises an issue in relation to communication between our hospital and the sleep apnoea clinic at St Thomas’. As you will appreciate, the clinic is operated by Guys and St Thomas’ NHS Foundation Trust which is separate from our hospital. We therefore clearly have no control over them, and vice versa. It is clearly important that information is passed appropriately between healthcare professionals to ensure that a patient’s care is dealt with as holistically and appropriately as possible. Our focus is on the treatement of mental illness. However, we do understand the need to work collaboratively and proactively to the benefit of our shared patients. When our patients are referred to this clinic, or indeed any other physical health clinic at St Thomas’, our medical staff provide a handover to St Thomas’ and the care in relation to those aspects is then transferred to those physical care specialists. With that in mind, and following the inquest into the death of Mr Bates when you indicated your roposal to make this report, my hospital manager at Cambian Churchill Hospital has met with ee] at St Thomas’ and agreed a protocol going forward to cover the matter set out in the attached document, in order to reduce the possibility of inadequate communication or care in the future. 4" Floor, Waterfront Bullding, Chancellors Road, Hammersmith Embankment, London, W6 9RU Tel: +44 (0)20 8735 6150 Fax: +44 (0}20 8735 6151 ywww.cambiangroup.corm R The Cambian Group comprises a number of companies which aie registered in England and Wales and the Bailiwick of Jersey. The details of those companies in the Cambian Group registered in England and Wales can be found al www.cambiangroup.com/aboul/legal tf ae Cambian I hope that this letter provides you with the information that you were seeking and I am grateful to you for bringing this matter to my attention. Should you have any further concerns on this or any other matters, please feel free to contact our Group Director of Risk & Quality, Philip King. Yours sincerely Saleem Asaria Chief Executive Cambian Group 4+ Floor, Waterfront Building, Chancellors Road, Hammersmith Embankment, London, W6 9RU Tel: +44 (0}20 8735 6150 Fax: +44 (0}20 8735 6151 www.cambiangroup.com Re The Cambian Group comprises @ number of companies which ore registered in England and Wales and the Bailiwick of Jersey. The details of those companies in the Cambion Group registered in England and Wales can be found at wwww.cambiangroup.com/about/legal
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