Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0075, written 26 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Feb 2016 |
|---|---|
| Reference | 2016-0075 |
| Deceased | Devinder Seth |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Alwen Williams, Chief Executive, Barts Health, Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB 1 | CORONER | am Nadia Persaud, Senior Coroner for the Coroner area of East 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:/Awww.legislation.gov.uk/uksi/2013/1629/part/7/made 3 | INVESTIGATION and INQUEST On the 15"" May 2014, | commenced an investigation into the death of Mr Devindar Lal Seth. The investigation concluded at the end of the Inquest on the 23 February 2016. The conclusion of the Inquest was a narrative conclusion: Mr Seth suffered a fractured hip following a fall at his home on the 1 4" July 2013. He was admitted to Newham General Hospital where he underwent a dynamic hip screw procedure. Post-operatively, his pain was managed with opiate medication. He showed signs of opiate accumulation from the 1 9" July 2013. This was not identified or addressed until family members raised the alarm on the 23 July 2013. When the opiate toxicity was identified, Mr Seth was transferred to ICU for close monitoring. He suffered aspiration on the ICU at around 18:50 on the 24” July 2013. Ventilation was required at this time, to robustly protect his airway. Ventilation was not carried out promptly after the aspiration and Mr Seth suffered a cardiac arrest at 23:45. Prompt ventilation following the aspiration at 18:50 on the 24" July 2013, would have prevented the cardiac arrest and his death on the 24" August 2013 would have been avoided. 4 | CIRCUMSTANCES OF THE DEATH Mr Seth was a 94 year old gentleman who suffered a fall at his home on the 14" July 2013. He was admitted to Newham General Hospital in the early hours of the 15" July 2013 and underwent surgery to repair a fractured hip, on the 16" July 2013. Post-operatively, Mr Seth’s pain was initially managed with an epidural. During the period in which the epidural was in situ, he underwent close observations. The epidural was removed on the 18" July 2013 at 08:15. Following the removal Mr Seth suffered from pain and opiate medication was introduced in the form of oromorph and codeine. He had also received fentanyl via the epidural. Mr Seth underwent 4-6 hourly observations from the 18" July to the 21 July 2013. (consultant physician) confirmed that having reviewed the notes it was apparent that Mr Seth was suffering from opiate toxicity from the 19" July 2013. Members of the family recognised the signs of opiate toxicity (excessive drowsiness and pinpoint pupils) and raised the alarm with hospital staff. Following this a review took place by the critical care outreach team and Mr Seth was transferred to ITU. Administration of naloxone resulted in an improvement to Mr Seth’s condition, therefore confirming the opiate accumulation. Mr Seth suffered an episode of aspiration on the 24" July 2013 at 18:50. Ventilation was not carried out in time and he suffered a cardiac arrest at 23:45 on the 24” July 2013. Following the cardiac arrest Mr Seth deteriorated as a result of both sepsis and multi- organ failure. 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. — During the Inquest | heard evidence in relation to the risks of orthogeriatric patients being placed on opiate medication. | was informed that these risks include slow metabolism of these drugs (particularly in the elderly), constipation, confusion, hallucinations, respiratory depression and excessive drowsiness. There is no indication within the medical records that the side effects from the opiate medication upon Mr Seth were considered by the ward staff and his care plan adjusted accordingly. It was a family member who raised the alarm regarding opiate toxicity, based upon the pinpoint pupils and excessive drowsiness. The alarm was raised by the family member on the 21° July 2013 confirmed that there was evidence of opiate accumulation from the 19” July 2013. During the course of the evidence, it was confirmed that there is no clear guidance available to ward staff on the risk of opiate medications in orthogeriatric patients and side effects to look out for. | have been provided with the WHO Analgesic Ladder and the Guidelines for Acute Pain Management in Adults. The guidelines provide substantial amounts of information in relation to the contra-indications of NSAIDs. The only information relating to opioids in the Guidelines is that regular opioids can cause constipation. It is clear that none of the ward staff in this case recognised the effect that the opiate medication was having upon Mr Seth and | consider that it would be helpful for easily accessible guidance to be available for both nursing and medical staff. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 20" April 2046. |, 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 ry a copy of my report to the Chief Coroner and to (son) and |_| (son). | am also forwarding a copy to the Care Quality Commission and toll WERE (Director of Public 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] AG: A. IG [SIGNED BY CORONER] inl
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.
Barts Health INHS| NHS Trust Professor Alistair Chesser Chief Medical Officer Barts Health NHS Trust Trust Executive Offices Ground floor, Pathology Block The Royal London Hospital London, E1 2ES Telephone: 020 32460632 www.bartshealth.nhs.uk Ms Nadia Persaud Senior Coroner for East London Walthamstow Coroner’s Court Queens Road Walthamstow London E17 8QP 31 March 2016 By special delivery Dear Ma’am, Inquest touching the death of Devindar Lal SETH | write in response to a Regulation 28, Report to Prevent Future Deaths, dated 26 February 2016, which was made at the conclusion of the inquest into the death of Devindar Lal Seth. Barts Health NHS Trust takes Coronial investigations very seriously and | am sorry you have had to make Preventing Future Death recommendations and | am grateful to you for highlighting your concern and will ensure that action is taken to address this. | note that the cause of Devinder Lal Seth’s death was multi organ failure as a consequence of sepsis from aspiration pneumonia resulting from a fractured right hip. You raised concerns involving the recognition of the signs of opiate toxicity in Mr Lal Seth. The concern you raised in the Preventing Future Death report is: 1. You felt that none of the ward staff in this instance recognised the effect that the opioid medication was having upon Mr Seth. This led to Mr Seth suffering from opiate toxicity. You considered that it would be helpful if there was easily accessible guidance available for staff. We have investigated the above concern and | can confirm: 1. Your report has been discussed at the latest Quality and Safety Committee (QaSC) and at the Hospital Management Board at Newham University Hospital. Posy, %, EAB Vy ef Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, The Royal London Hospital, St Bartholomew's Hospital and Whipps Cross University Hospital. dads Sait Barts Health INHS| NHS Trust . The Pharmacy department is producing guidance for staff relating to the risk of Opiate medications, their side-effects and the signs of opiate toxicity. 3. This guidance will be cascaded to all members of the ward and to medical staff and the communication manager will include the guidance as an article in the Newham University Hospital site newsletter. 4. The Pharmacy department is producing a ‘share the learning’ bulletin relating to this incident, this will be shared with all Pharmacists across all Barts Health NHS Trust sites. 5. The Acute Pain team in conjunction with the Trust's Pharmacy department are exploring additional options to highlight the monitoring required when using opioid medications. This will include additional nurse training in conjunction with improved use of observation charts. 6. Newham University Hospital is planning to review all of its Serious Untoward Incidents (SUI’s) that were reported from 2013 to date to identify if there are any opiate related SUI’s and if the lessons learnt from this incident can be retrospectively actioned. 7. The clinical lead for Care of the Elderly at Newham University Hospital now reinforces on a daily basis with the Foundation Year 1 and 2 (FY1 & FY2) doctors working in this area the need to recognise opiate toxicity and to escalate when appropriate. 8. The Matron for surgery at Newham University Hospital is in the process of retraining all nursing staff in relation to opioid toxicity and is also ensuring that health care assistants, who undertake patient observations, are being trained to recognise opioid intoxication. The Trust is aiming for this to be completed by the end of April 2016. lam once again grateful to you for bringing this case to my attention and | hope this letter fully answers the concerns you have raised. Yours faithfully Lite (lems Professor Alistair Chesser Chief Medical Officer Barts Health NHS Trust Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital, The Royal London Hospital, St Bartholomew’s Hospital and Whipps Cross University Hospital.
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