Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0417, written 30 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Oct 2015 |
|---|---|
| Reference | 2015-0417 |
| Deceased | Mary Bloom |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, Matthew Hopkins, Barking, Havering & Redbridge University Hospitals NHS Trust. Executive Offices, Queens Hospital, Rom Valley Way, Romford, Essex, RM7 0AG. 1 | CORONER | am Nadia Persaud, Senior Coroner for the Eastern Area 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. http://www .legislation.gov.uk/uksi/2013/1629/part/7/made 3 | INVESTIGATION and INQUEST On the 27" February 2014 | commenced an investigation into the death of Mary Catherine Bloom. The investigation concluded at the end of the Inquest on the 30" October 2015. The conclusion of the Inquest was a short form conclusion of natural causes. 4 | CIRCUMSTANCES OF THE DEATH Mary Catherine Bloom suffered from dementia. There was a 12 month history of cognitive decline and reduced oral intake. She was admitted to Queens Hospital on the 3" February 2014 with a history of 3 weeks of significantly reduced oral intake and rapid change in her left leg over 4 hours that morning. The initial impression was that Mrs Bloom was suffering from probable ischemia in the leg, hypovolemia and general decline. She was admitted under the care of the vascular surgical team. The plan in place was for her to receive intravenous fluids, antibiotics and heparin. She was not considered to be a candidate for surgery. The heparin was not expected to reverse the thrombosis but to prevent further deterioration. A loading dose of 5000units of heparin was administered at 17:40 and an infusion of 20,000 units put up at 18:30. Mrs Bloom’s weight was not recorded prior to the administration of heparin or at all during her admission. The infusion rate was not calculated on the basis of her weight, as it should have been. The Trust policy requires baseline bloods to be taken and then APTT ratios to be checked every 6 hours. Baseline bloods were not taken, as bloods were haemolysing in A & E. They also haemolysed when an attempt was made by the surgical registrar. There was no attempt to repeat bloods after hydration had commenced. There was no consultation with the consultant haematologist in view of Mrs Bloom’s very low weight of 30 kilograms. The haematologist is likely to have advised a reduced loading dose and a reduced infusion rate. Mrs Bloom was admitted to the ward at 20:00 hours and was noted to have a reduced blood pressure at 21.50. The nurse caring for her also questioned the possibility of melena. A doctor attended the ward to review Mrs Bloom and considered that the drop in blood pressure was due to dehydration. Fluids that had been written up previously were not ongoing and therefore he re-sited the cannula and advised that fluids be recommenced at a slightly increased rate. At around 23:45 the nurse caring for Mrs Bloom noted that her condition was deteriorating. She was noted to have passed away at 00:50 on the 4" February 2014. CPR was not attempted as a DNAR order had been put into place by the consultant in charge of her care. There was no discussion with the next of kin prior to placing the DNAR order in her notes. The pathologist who carried out the post-mortem examination did not find any evidence of bleeding and did not consider that excessive administration of heparin had contributed to Mrs Bloom’s death. The pathologist gave a cause of death 1a dementia and II coronary artery atheroma; mitral valve disease and acute limb ischaemia 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. There was a failure to comply with the Trust's policy relating to the administration of heparin, by failing to weigh Mrs Bloom prior to commencing the infusion of heparin. 2. There was a failure to consult a haematologist before the infusion of heparin in view of Mrs Blooms’ very low weight of 30 kilograms. Again, this is required by the Trust policy. 3. It was not possible to take baseline bloods before the commencement of heparin, however, attempts should have been made to retake bloods after hydration had commenced. The Trust policy requires baseline bloods to be taken and for the APTT to be checked after 6 hours. The consultant haematologist who gave evidence from the Trust confirmed that he should have been consulted, the weight should have been clearly recorded and bloods should have been attempted post-hydration. He agreed that a specially tailored administration of heparin form, requiring the documentation of the patient's weight and APTT ratio would improve the safe administration of the drug. The poster for the administration of heparin include a direction that: An obese/underweight patient who weigh over 131 kilograms and under 40 kilograms should be treated on an individual basis. Please seek haematology advice. This direction is written in very small writing at the bottom of the heparin administration poster. It appears to have been missed by 2 doctors involved in the prescribing of heparin to Mrs Bloom. There is concern that this may have been missed as it was not sufficiently visible on the poster. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and 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 29" December 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 |_am_also forwarding a copy of the report to the Care Quality Commission and of (director of public health) who may find it useful or of interest. | 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. 30" October 2015 [SIGNED BY CORONER] Ly \ hw
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.
Barking, Havering and Redbridge NHS: University Hospitals NHS Trust Ms Nadia Persaud Executive Offices Senior Coroner for the Eastern District Queen's Hospital of Greater London, Rom Valley Way, Romford, Essex RM7 OAG Walthamstow Coroners Court, Queens Road, Tel: 01708 435 444 Walthamstow, www.bhrhospitals.nhs.uk London E178QP Y @BHR_hospitals 18" January 2016 Dear Nadia, Thank you for your letter dated 8" December 2015 with regards to some outstanding concerns that you have raised in relation to the inquest of Mary Catherine Bloom that resulted in a Regulation 28 being served to the Trust in November 2015. In your letter you acknowledge receipt of three new policies that have been put in place by the Trust following the inquest and the new chart that has been introduced for the administration of unfractionated heparin. You have however raised further concerns with regards to the new Trust guidelines that have removed the requirement for a haematologist to be consulted where a patient is at the extremes of weight. The reasoning for this decision is as follows. The Trust’s new policy is for a weight based bolus and then a weight based infusion the latter within weight ranges. Even with a patient of 25kg the infusion would be at 20iu/kg/hr which is a very reasonable infusion rate and in line with recognised dosage rates even at this weight. The APPTR must be checked at 6hours and this allows the dose to be adjusted within recognised time intervals. We therefore feel that the safeguards are, in place as we have moved to an entirely weight based formulation. As an extra safeguard the guideline, following the concerns you raised, now also states that if the APTTR at 6hrs is outside the expected range then the Consultant Haematologist should be contacted for further advice in those patients at the extreme ends of the weight ranges i.e. <41kg and >90kg. | hope that this provides you with the assurance that you require and that I can look forward to hearing from you to confirm that this regulation 28 has now been closed. Yours sincerely, Matthew Hopkins Chief Executive RO i, om FREP EVV = § FETY UCL Partners had a ers) Mae on SMOKEFREE Chair: Dr Maureen Dalziel MD MBChB FFPH Chief Executive: Matthew Hopkins
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