Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0305, written 23 Aug 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Aug 2016 |
|---|---|
| Reference | 2016-0305 |
| Deceased | Michael Dundon |
| Coroner | David Hinchliff |
| Coroner area | West Yorkshire (East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Leeds Teaching Hospitals 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an Inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Rt Hon Jeremy Hunt MP, Secretary of State for Health, Department of Heaith, Richmond House, 79 Whitehall, London, SW1A 2NS 1 | CORONER | am David Hinchliff, Senior Coroner, for the coroner area of West Yorkshire (Eastern). 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. 3 | INVESTIGATION and INQUEST On 12" November 2015 | commenced an investigation into the death of MICHAEL DUNDON, aged 73. The investigation concluded at the end of the Inquest on 8° fh August 2016. The conclusion of the Inquest was Accidental Death. “Michael Dundon suffered with mental health problems which had caused changes to his personality, which had caused him to become violent on occasions, which made him unsuitable to remain a resident at Copperhill Nursing Home. He was admitted to St James’s University Hospital, Leeds where he should have been supervised on a one to one basis, but there was a period when he was unsupervised, which enabled him to ingest safety gel liquid absorbing crystals which had been placed in unused urine bottles in his room. The crystals solidified causing a blockage to his airways and causing his death to be confirmed at 0615 hours on 11" November 2015 on Ward J14 at St James's University Hospital. The safety gel was not recognised at the time as being a risk to patients or visitors by ward staff. The cause of death was 1(a) Aspiration of foreign material into the airway and (2) Micro-infarcts in the brain with leukomalacia caused by cerebral arteriolosclerosis. 4 | CIRCUMSTANCES OF THE DEATH Michael Dundon died due to asphyxiation on safety gel liquid absorbing crystals. He had access to the liquid absorbing crystals as they had been placed in unused urine bottles in his room. The manufacturer's guidance states that safety gel sachets should be placed in urine bottles prior to use. The safety gel was not recognised as a risk to patients or visitors by staff on the ward. 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. The MATTERS OF CONCERN are as follows. — (1) | understand that liquid absorbing crystals in sachet form are used throughout NHS ___| - England. The crystals are a nationally recognised product available from the NHS supply chain and used nationwide. There are variations in practice regarding the use of the gel sachets. (2) The liquid absorbing crystals are a dry granule that quickly dissolve to absorb liquid. The sachet is placed into a urinal bottle, bed pan or vomit bowl to ensure a swift absorption of unwanted liquids. The sachet opens on contact with a liquid and the granules quickly absorb up to 4.2 litres of hazardous/unwanted liquid. A manageable dwell is formed to be safely disposed of which reduces the risk of infections and spillage. In the original form the sachets could be mistaken for salt or sugar. (3) The crystals had been pre-inserted into two empty urine bottles in the deceased’s room. The staff did not recognise that such sachets could be hazardous when left in this way. The deceased was able, whilst unsupervised, to swallow crystals, causing a cardiorespiratory arrest and death. (4) The risks associated with the use of these crystals may not be fully understood. (5) The manufacturer of the product has been informed and the packaging has already been changed and a display poster has been produced for display in relevant clinical areas. (6) All relevant staff throughout the country need to be made aware as to the harm to a person if the crystals are ingested, and an appropriate risk assessment should be carried out. (7) | request that the Secretary of State bring this to the attention of all NHS Trusts so that risk assessments, staff awareness and training can be carried out. 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 by Tuesday 48" October 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: ei Officer of the Leeds Teaching Hospitals NHS Trust Department of Corporate Services Division, Leeds Teaching Hospitals NHS Trust Headquarters, St James's University Hospital, Beckett Street, Leeds, LS9 TTF I have also sent it to () 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 ina 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. 9 | Date 23 August 2016 [SIGNED BY CORONER] | ‘ Ai we e / lL
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.
we Philip Dunne MP Minister of State for Health Department of Health richmond Mouse 79 Whitehall London SWIA 2NS Tel: 020 7210 4850 David Hinchliff HM Senior Coroner — West Yorkshire (Eastern) Coroner’s Office and Court 71 Northgate £3 MAR 2017 Wakefield WFI 3BS Thank you for your letter of 23 August 2016 to Secretary of State about the death of Michael Dundon. I am responding as the Minister with responsibility for patient safety at the Department of Health. I was saddened to read of the circumstances surrounding Mr Dundon’s death. Please pass my condolences to his family and loved ones. I would also like to apologise for the delay in responding. I am advised that Departmental officials sought further information about the nature of the product to help with their enquiries and I am grateful to you for facilitating this. The Department has liaised with a number of agencies to ascertain where responsibility lies for determining the most appropriate response to your concerns, As you may know, as of 1 April 2016, patient safety transferred from NHS England and is now part of NHS Improvement. NHS Improvement provides a leadership role for patient safety in the NHS in England and provides advice and guidance, including through patient safety alerts, to support all providers of NHS- funded care to identify, understand and manage risks to the safety of patients. The Department approached NHS Improvement for its advice on 23 January. NHS Improvement recognises and shares your concerns that the sachets of solidifying crystals used widely within the NHS in human waste receptacles can present a choking hazard if put in the mouth by patients. I am advised that since becoming aware of the findings of the inquest into Mr Dundon’s death, NHS Improvement’s Patient Safety Team has been working to identify an effective method of risk reduction. This work will include consideration of a warning to staff of the risk presented and the need for risk assessment as you recommend. However, I am advised that initial considerations by NHS Improvement, are that any such warning would have a limited effect, as a high proportion of hospital inpatients have some degree of cognitive or visual impairment, and confused patients might typically pick up urine bottles or other receptacles from other patients. NHS Improvement has further advised that any blanket restriction on their use potentially also risks patient harm through making handling and disposal of bodily fluids more difficult, with an impact on infection control procedures, as well as affecting patient comfort and dignity. A further consideration is that the use of the sachets appears very widespread, including outside hospital settings. For example, to aid safe disposal of vomit or urine spills in a variety of settings such as nurseries, nightclubs and police cells. Although the manufacturers of these products label them with clear instructions that they are dangerous if put in the mouth, small children, or people who might be under the influence of drugs or alcohol might not read or understand such warnings. NHS Improvement will follow up this angle with the Health and Safety Executive (HSE). Finally, NHS Improvement is exploring whether a safe alternative or alternative ways of using the solidifying crystals that would mean reduced risk without a loss of the benefits they bring to infection control and patient comfort, exists. Once NHS Improvement has identified the most effective way of managing the choking hazard while ensuring infection control benefits can be maintained, it intends to notify providers of NHS-funded care. NHS Improvement will liaise with the Care Quality Commission to ensure that any advice or guidance is also distributed to care homes and hospices. I would add that the Secretary of State for Health announced a package of measures in December 2016 to improve the way Trusts and Foundation Trusts identify and learn from deaths of patients in their care. This includes a requirement for trusts to collect a range of specified information on deaths that were potentially avoidable and serious incidents and consider what lessons need to be learned ona regular basis, cd Department of Health T hope this information is helpful. NHS Improvement has undertaken to update you as it takes this matter forward and I have asked that my officials are kept informed of developments. Thank you for bringing the circumstances of Mr Dundon’s death to our attention. foes fu ) PHILIP DUNNE
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