Prevention of Future Deaths reports · 2016

James Kane

Regulation 28 report to prevent future deaths, reference 2016-0253, written 15 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report15 Jul 2016
Reference2016-0253
DeceasedJames Kane
CoronerAndrew Tweddle
Coroner areaCounty Durham and Darlington
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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:

1. County Durham and Darlington NHS Trust
2. Department of Health

CORONER

lam Andrew Tweddle Senior Coroner for the coroner area of County Durham and
Darlington.

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.
(see attached sheet)

INVESTIGATION and INQUEST

On 12" January 2016 | commenced an investigation into the death of James Kane, 52
years. The investigation concluded at the end of the inquest on 14" July 2016. The
conclusion of the inquest was Recognised Complication of Necessary Medical
Intervention with a cause of death of 1a) Peritonitis, 1b) Bowel Injury following
Paracentesis for Ascites, 1c) Alcoholic Liver Disease including Cirrhosis.

CIRCUMSTANCES OF THE DEATH

The deceased was admitted to hospital with gross ascites secondary to advanced liver
cirrhosis. There had been some occasions where drains had been inserted following an
ultrasound scan but some occasions where drains had been inserted without an
ultrasound scan. On 2% January 2016 a drain was inserted without a scan and some 7
and a half litres of fluid were drained prior to the drain being removed in the early hours
of 3% January. Within an hour of the drain being removed the deceased's condition had
deteriorated markedly and he died later that day. It was accepted that the deceased had
died of a well-known but rare medical complication. It is likely that at the time the drain
was inserted an injury was sustained by the bowel. A consultant gave evidence to say
that there was nothing in hospital guidelines to mandate an ultrasound scan prior to the
insertion of a drain; that this was a very common procedure and that intuitively it would
seem to be beneficial to have a scan prior to a drain being inserted. The matter had
been referred to hospital authorities at a regional level and there was no support for a
proposition that there should be a scan prior to the insertion of a drain. The family clearly
took the view that their loved one would not have died at the time that he did but for the
insertion of the drain and that, if a scan had been undertaken, this might have reduced
the risk. They feel their loved one could have been that “1 in a million" and in their view
therefore further consideration should be given to the risk.

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. —

Notwithstanding that a local discussion of the circumstances of this case has taken
place and there having been no local support for a change in policy or guidance, given
the evidence that the deceased would not have died when he did but for the drain and
that it is possible that a scan may have reduced the risk of death | believe this is a
matter that requires further thought and consideration.

SS eee |

8 | COPIES and PUBLICATION

|

In my opinion action should be taken to prevent future deaths and | believe you and your
organisation] have the power to take such action.

ACTION SHOULD BE TAKEN

YOUR RESPONSE

You are under a duty to respond fo this report within 56 days of the date of this report,
namely by 9"" September 2016. I, 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.

| |have sent a copy of my report to the Chief Coroner and to the following Interested
| Persons; Care Quality Commission and

lam 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.

Signed...\wd so. wre Se \o

HM SENIOR CORONER
COUNTY DURHAM AND DARLINGTON

Dated. Vso \\ \ \o

Responses

2 responses 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.

Response from County Durham and Darlington NHS Trust (PDF)
County Durham and Darlington NHS)

NHS Foundation Trust

Executive Corridor
Darlington Memorial Hospital
Hollyhurst Road

Darlington, DL3 GHX

c-

Your Ref:
Our Ref:
5" September 2016

H.M Coroners Office
PO Box 282

Bishop Auckland
Co. Durham

DL14 4FY

Dear Mr Tweddle

| am writing in response to the Regulation 28 issued on the 15th July 2016. The content of
the Regulation 28 has been given due consideration and an action plan put in place to
reduce any risk of future harm of a similar incident occurring to patients in our care.

Mr Kane was a gentleman with a history of severe alcoholic liver cirrhosis (Child’s C). Prior to
his death, he had multiple episodes of complication from the liver cirrhosis requiring
admission to the hospital for treatment. One of the main issues was development of fluid in
the abdomen (ascites) which required regular drainage via insertion of an abdominal drain
(paracentesis).

Mr Kane unfortunately passed away on the 3rd of January 2016 at 12:40pm.

An inquest was held on the 14th of July 2016. The events were recognised as complications
of necessary medical intervention with the cause of death as

1a) Peritonitis
1b) Bowel injury following paracentesis for ascites
1c) Alcoholic tiver disease including cirrhosis.

Prior to this Mr Kane had undergone 5 large volume paracentesis of which the first two were
done with ultrasound marking. The subsequent procedures were done without any ultrasound
marking and there had been no complications.

www.cddft.nhs.uk
Chief Executive. Darlington Memorial Hospital, Hollyhurst Road,
Darlington, County Durham DL3 6HX

Aem au} je ¢ noA uM

County Durham and Darlington INHS|

NHS Foundation Trust

The complication from this procedure was reported on the hospital’s safeguard system and a
root cause analysis (RCA) was undertaken. The procedure was performed by the appropriate
level of doctor who has previously been assessed and had achieved documented
competency for the procedure. A written consent was obtained from Mr Kane, the procedure
was appropriately documented and no immediate complication was noted. A post-procedural
plan was left in place and the patient had his observations monitored appropriately.
Unfortunately a perforation did occur which subsequently led to generalised peritonitis.

The national guidance on management of ascites from the British Society of
Gastroenterologist was reviewed (Moore et al, Guidelines on the management of ascites in
cirrhosis, 2006) and the followings were noted from its recommendations

- Therapeutic paracentesis is the first line treatment for patients with large or refractory
ascites.

- Large volume paracentesis with colloid replacement is rapid, safe and effective

There is no mention of the role of ultrasound guidance in the placement of ascitic drain. The
regional guidelines from the Gastroenterology Specialist Training Committee do not
recommend the routine use of ultrasound for therapeutic paracentesis in liver cirrhosis.

The European guidance on the management of ascites from the European Association for
the Study of the Liver was also reviewed (Gines et al, EASL clinical practice guidelines on the
management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in
cirrhosis, 2010) and the followings were noted from its recommendations

- Large volume paracentesis is the treatment of choice for the management of patients
with grade 3 ascites.
- Large volume paracentesis is a safe procedure and the risk of local complications,
such as haemorrhage or bowel perforation is extremely low.
There is no mention of ultrasound guidance in the management of the ascitic drain in this
document.

The most recent guidance was published by the American Association for the Study of Liver
Disease (B Runyon, Management of Adult Patients with Ascites Due to Cirrhosis: Update
2012). The followings were noted from its recommendations

- Serial paracenteses are a treatment option for patients with refractory ascites (Class 1,
Level C)

- Although more serious complications (hemoperitoneum or bowel entry by the
paracentesis needle) occur, they are sufficiently unusual (<1/1,000 paracenteses) that
they should not deter performance of this procedure.

www.cddft.nhs.uk
Chief Executive. Darlington Memorial Hospital, Hollyhurst Road,
Darlington, County Durham DL3 6HX

Aem au} |je 4 NoA Uy

County Durham and Darlington INHS|

NHS Foundation Trust

- In recent years, new paracentesis equipment (eg. multihole, large-bore needle and a
pump) have become available that may improve the ease and speed of therapeutic
paracentesis.

With regards to the use of abdominal ultrasound, the guideline states “If the fluid is difficult to
localise by examination because of obesity, ultrasonography can be a useful adjunct in
locating fluid and visualising the spleen and other structures to be avoided.”

The current departmental practice is in keeping with published guidance in that paracentesis
is normally done at the bedside with ultrasound guidance only being undertaken when there
are concerns such as the presence of previous surgical scars or uncertainty on the presence
of ascitic fluid. Ultrasound is not used routinely in large volume paracentesis in patients with
liver cirrhosis who have well documented ascites and have previously undergone
paracentesis.

As NHS professionals the gastroenterology team have discussed the serious incident with
their colleagues’ at the British Society of Gastroenterology and clarified that their current
practice does meet the standard of our professional body. They appreciate that the field is
continually evolving and that the hepatology section of the British Society of Gastroenterology
is reviewing the paracentesis service as a whole.

The current guidance does not recommend the routine use of abdominal ultrasound in
managing large volume paracentesis. It describes the procedure as effective and safe with a
very low risk of local complications. The decision on whether abdominal ultrasound may
reduce the risk of complication is not supported by current evidence at the present time, and
any change fo the guidance in the future will be appropriately incorporated in the Trust's
practice. Notwithstanding this, the Trust has recognised actions that need to be taken both in
the short term and longer term.

Recommendations

1. To continue to provide a timely and safe service to all liver patients who require
paracentesis in adherence to national guidelines. All trainees will be provided with a
copy of the guidance.

2. Ensure that there is a clear audit trail of patients having undergone paracentesis within
CDDFT. This will include the development of a proforma and database which will
include

i.Patient demographics
ii. Date procedure performed
ii. Clinician performing the procedure
iv.Any complications during or post procedure

www.cddft.nhs.uk
Chief Executive. Darlington Memorial Hospital, Hollyhurst Road,
Darlington, County Durham DL3 6HX

uM

<

Aem au} jje ¢ no

County Durham and Darlington NHS;

NHS Foundation Trust

A lead person will be identified on the Acute Medical Units and Gastroenterology wards
across CDDFT and a meeting will be held 3 monthly to reflect on the management of
this patient cohort.

3. All procedures will be performed between the hours of 8am and 8pm so that any
complications can be identified and escalated to a senior decision maker.

4. A patient information leaflet will be available to all patients at the time of giving informed
consent which outlines the procedure and possible complications. This will aim to be in
place by 1°' September 2016.

Should you have any outstanding queries please do not hesitate to contact us again.

Yours Sincerely

SS Ss SD

Sue Jacques
CHIEF EXECUTIVE

www.cddft.nhs.uk
Chief Executive. Darlington Memorial Hospital, Hollyhurst Road,
Darlington, County Durham DL3 6HX

Aen au} [je ¢ noA yum
Response from Department of Health (PDF)
4 *
os Philip Dunne MP’
Minister of State for Health

Department
of Health |
Richmond House
79 Whitehalf
te Lond
§ SEP 2016 SWIA2NS
Mr Tweddle Tel: 020 7210 4850
Senior Coroner
Fourth Floor, Civic Centre
North Terrace
Crook

Co Durham DL15 9ES
a

Thank you for your letter of 15 July 2016, following the inquest into the death of
James Kane. I am responding as the Minister with responsibility for hospital care at
the Department of Health.

3 f AUG 2016

I was sorry to hear of Mr Kane’s death. Please extend my condolences to his family
and loved ones.

Your report explained that Mr Kane was admitted to hospital with gross ascites (build-
up of fluid) which was secondary to his advanced liver disease. On the 2 January 2016
he had a drain inserted to remove the fluid. This procedure (paracentesis) was carried
out without a prior ultrasound scan.

You explained that Mr Kane suffered an injury to the bowel, which is a recognised but
rare medical complication associated with paracentesis. You asked that we consider
whether insertion of a drain should always be preceded by an ultrasound scan.

I have consulted the National Institute for Health and Care Clinical Excellence (NICE)
on this matter and have been advised that their recently published guidance - Cirrhosis
in over 16s: assessment and management (NGS50) - does not make any
recommendations as to whether or not a scan should be taken prior to the insertion of a
drain for ascites. This guidance can be found at
https://www.nice.org.uk/guidance/ng50. The issue was not raised by stakeholders
during the NICE consultation on the guideline scope, nor by the scoping team, and it
was therefore not addressed during the development of the guideline.

NICE do not believe the guideline needs to be amended at this time. However, your
concerns have been highlighted to the guideline surveillance team, for their
information when the guideline is next considered for an update.

In addition, the Department of Health also consulted the Royal College of Radiologists
on the general issue as to whether ultrasound scanning should always be performed
immediately prior to drainage of abdominal ascitic fluid. They, in turn, sought advice
from the following:

* British Society of Gastrointestinal and Abdominal Radiology,

* British Society of Gastroenterology, and

* — British Society of Interventional Radiology.

The Royal College of Radiologists does not consider there is a case for the routine use
of ultrasound prior to or during paracentesis. It is the College's view that paracentesis
is a safe procedure when performed by trained, competent operators following
established guidelines on the appropriate use of the procedure.

I note that you report states that there is no support locally for a change in hospital
policy or guidance and this view appears to be supported by the advice I have been
given.

I hope that this reply is helpful and I am grateful to you for bringing the circumstances
of Mr Kane’s death to my attention.

PHILIP DUNNE

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