Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0143, written 12 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Apr 2016 |
|---|---|
| Reference | 2016-0143 |
| Deceased | Hayley Clark |
| Coroner | Mark Beresford |
| Coroner area | Yorkshire South (East District) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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Mark Andrew Beresford Assistant Coroner for South Yorkshire (East District) TT eee REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ms Louise Barnett, Chief Executive, Rotherham Hospital NHS Foundation Trust Moorgate Road Rotherham $60 2UD 1 CORONER | am Mark Andrew Beresford, Assistant Coroner for South Yorkshire (East District) 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/ukpga/2009/25/schedule/5/paragraph/7 http:/Avww.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 27/05/2015 | commenced an investigation into the death of Hayley Christine Clark, 36. The investigation concluded at the end of the inquest on 12 April 2016. The conclusion of the inquest was a Narrative conclusion as follows: Hayley Christine Clark died, at Rotherham Hospital, on 24th May 2015, from the effects of severe malnutrition. Her malnutrition arose from a combination of factors, which did not include anorexia, but which did include poor eating discipline due, in part, to longstanding abdominal discomfort. The cause of death was 1a. Respiratory failure, 1b Pulmonary oedema, 1c Severe multi-factorial malnutrition, 2. Acute pyelonephritis, electrolyte imbalance, anaemia and immune deficiency 4 CIRCUMSTANCES OF THE DEATH 1. Hayley Christine Clark was a 36 years old female with a medical background which included long term malnutrition, hypogammaglobulinemia, irritable bowel syndrome, anaemia and depression. 2. She was admitted to Rotherham General Hospital on 12'" May 2015 with electrolyte imbalance. 3. As part of a standard package of pain management, Ms Clark received Paracetamol. However the dose administered was the standard adult one and had not been adjusted to reflect Ms Clark’s extremely low (less than 50kg) body weight. This overdose of Paracetamol caused derangement of Ms Clark’s liver function. The problem was identified, the Paracetamol was withdrawn and Parvolex was administered. 4. Ms Clark’s condition deteriorated. She was transferred to the High Dependency Unit on 22™ May 2015 and she died on 24" May 2015. The cause of her death was as set out above. 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. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 The MATTERS OF CONCERN are as follows: (1) There was a failure, on the part of the staff who prescribed and administered the Paracetamol to Ms Clark, to recognise the need to adjust the dosage (in evidence the required reduction was said to be 50%) to reflect Ms Clark’s extremely low body weight. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Ms Louise Barnett, Chief Executive, 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 Tuesday 7th June 2016. |, 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 Persons: 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. Dated 12 April 2016 Signature_—<C-— Assistant Coroner for South Yorkshire (East District) Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365
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.
Rotherham Hospital Moorgate Road Oakwood Rotherham S60 2UD Telephone 01709 820000 www.therotherhamft.nhs.uk Our reference Your reference Date 6th June Address Strictly Private and Confidential Mr M A Beresford Assistant Coroner South Yorkshire (East District) Coroner’s Court and Office Doncaster Crown Court College Road Doncaster DN1 3HS Via Email Dear Mr Beresford RE: Ms Hayley Clark – Regulation 28 Firstly, I wish to state on behalf of The Rotherham NHS Foundation Trust, how sorry we are for the shortcomings in practice relating to Ms Clark’s care. We have taken the learning from our investigation and your concerns seriously in order to improve practice and take action to ensure that other patients do not have the same experience in future. Turning to the specific issues that you identified in your conclusion at the inquest on the 12th of April 2016: “There was a failure, on the part of the staff who prescribed and administered the paracetamol to Ms Clark, to recognise the need to adjust the dosage (in evidence the reduction was said to be 50%) to reflect Ms Clark’s extremely low body weight” I attach a copy of our additional action plan and can confirm that I am assured that the Patient Safety Group will oversee completion of the action plan. In the meantime please do not hesitate to contact me if you require any further information Yours sincerely Louise Barnett Chief Executive Enc Louise Barnett Chief Executive, The Rotherham NHS Foundation Trust Direct Line 01709 424576 Executive Assistant Sharree Johnstone Direct Line 01709 424001 Fax 01709 304200 Email sharree.johnstone@rothgen.nhs.uk ACTION PLAN - REGULATION 28 Action Plan: Regulation 28 – Prevention of future deaths Management of oral paracetamol for adult patients of extremely low body weight. Date Issued: 30th May 2016 (Version 1) Action Plan Lead: Chief Pharmacist and Assistant Director of Patient Safety Action Plan Review Dates: Monthly by Medication Safety Group To be signed off by the Patient Safety Group by September 2016 provided evidence of all actions is available. This action plan is dated the 30th May 2016 and relates to concerns identified at the inquest into the death of Ms Hayley Clark who was admitted to The Rotherham NHS Foundation Trust (TRFT) with electrolyte imbalance. She had a medical background which included malnutrition, hypogammaglobulinemia, irritable bowel syndrome, anaemia and depression. As part of her pain management Ms Clark received paracetamol. However the dose administered was the standard adult dose and did not reflect Ms Clarks extremely low body weight. The overdose caused derangement of her liver function. The issue was identified and the paracetamol withdrawn and Parvolex administered. The cause of death which was recorded by HM Coroner as: 1a) Respiratory Failure 1b) Pulmonary oedema 1c) Severe multifactorial malnutrition 2) Acute Pyelonephritis, electrolyte imbalance, anaemia and immune deficiency. Following the inquest HM Coroner identified: There was a failure on the part of the staff who prescribed and administered the paracetamol to recognise the need to adjust the dosage (in evidence the required reduction was said to be 50%) to reflect Mrs Clark’s extremely low body weight. Objective 1. Ensure the Trust’s Medicines Management Policy includes the safe prescribing and administration of medication for patients with extremely low body weight. ACTION PLAN – REGULATION 28 Who will take the action? Chief Pharmacist and the Trust’s Pharmacist designated as the Medication Safety Officer / Assistant Director of Patient Safety and the Chair of the Medication Safety Group Action Required See notes in far right column regarding research undertaken to inform this action plan 1.1 Review of the Trust’s Medicines Management Policy and/or the development of further local guidelines/Standard Operating Procedure or a Patient Group Directive which must include information for all prescribers of the need to be aware of possible dose reduction of drugs for patients with extremely low body weight. What timescale has been set and agreed? As the British National Formulary (BNF) does not currently provide dosage reduction recommendations the Trust’s Chief Pharmacist has sought advice from the Medicines and Healthcare products Regulatory Agency (MHRA) who have recently reviewed the publication of a paper from Birmingham Trust; whilst body weight alone is not considered a marker for an increased risk of oral paracetamol toxicity, an adult weighing less than 50kgs is more likely to have conditions that predispose them to liver damage from the paracetamol. A dose reduction to 2-3g total daily dose may be warranted. The MHRA are not currently recommending a change to the licences of oral paracetamol products, or a change to the packaging of the paracetamol products for the public to buy. Local guidelines /Standard Operating Procedure or a Patient Group Directive to be completed by September 2016 1.2 A pharmacy medications information leaflet to be produced on reducing the dose of oral paracetamol for patients who weigh less than 50kgs and/or with medical conditions which may require consideration of dose reduction – malnutrition/anorexia or high alcohol consumption all of which are known indications for considering a dose reduction of oral paracetamol Chief Pharmacist and the Trust’s Pharmacist designated as the Medication Safety Officer The Trust information leaflet must be approved by the Trusts Medication Safety Group by July 2016 and available on the Trust’s intranet by August 2016. Information added to the Trust electronic information for junior medical staff by August 2016. 2. Ensure all nursing and medical colleagues identify adult patients with extremely low body weight who may need adjustment in the dosage of oral paracetamol ACTION PLAN – REGULATION 28 1.3 Development of stickers to be used on the Trust’s prescription charts to raise awareness and compliance with the dose reduction guidance of oral (and IV) paracetamol 2.1 All nursing and medical staff who prescribe and administer medication to be provided with information on how to adjust the dosage of paracetamol for adult patients with extremely low body weight 2.2 A record of all staff who require and have received appropriate training - on dosage reduction; will be collated to ensure all appropriate nursing and medical colleagues have received this in the required timescale 2.3 Review of documentation to ensure accurate recording of patients weight in the clinical records, nursing records and prescription charts 2.4 Audit to be undertaken to assess the equipment available across the Trust for weighing patients. Chief Pharmacist and the Trust’s Pharmacist designated as the Medication Safety Officer. The stickers must be approved by the Trust’s Medication Safety Group by July 2016 and available by August 2016 or any delay in the production and compliance with this completion date escalated to the Trust’s Medication Safety Group Chief Pharmacist and the Trust’s Pharmacist designated as the Medication Safety Officer This information for staff will be developed by 31 August 2016. Chief Pharmacist and the Trust’s Pharmacist designated as the Medication Safety Officer All staff requiring additional training will have received this by October 2016. Attendance will be collated at the time of attendance Heads of Nursing/Matrons/Ward Managers/Ward pharmacists Patient Safety Team with the Critical Care - outreach team Training will also be on-going and provided on induction to appropriate colleagues (from September 2016) An audit of documentation of weights recorded in relevant nursing records and charts and on prescription charts will be undertaken by August 2016 and the results presented to the Patient Safety Group by September 2016 Audit to be completed by July 2016 and a business case for any additional equipment will be presented to the Trust’s Medical Device Management Group (MDMG) by August 2016. ACTION PLAN – REGULATION 28 2.5 A learning event to be held to discuss the details of this specific case The Pharmacy Department and Patient Safety team will deliver the learning event session A learning event session will have been delivered by 30th September 2016 as part of the SAFETEMBER safety work to be undertaken in September 2016. The changes in practice will be communicated in the Quarter 2 Patient Safety ‘lessons learnt’ newsletter due to be published September 2016. Action Plan developed by: Osman Chohan Chief Pharmacist and Fiona Middleton Assistant Director of Patient Safety Version Control: Version 1 Date: 30th May 2016 Circulation List: Divisional Clinical Directors, All Consultant colleagues, Clinical Pharmacists, Heads of Nursing, Matrons, Ward Managers Medical Education and Practice Development teams.
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