Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0321, written 7 Sep 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Sep 2016 |
|---|---|
| Reference | 2016-0321 |
| Deceased | Dildar Shariff |
| Coroner | Julie Robertson |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Health 2. NICE 3. Pennine Acute NHS Trust 4. Chief Coroner CORONER I am Ms Julie Robertson, Assistant Coroner for the Coroner area of Manchester North 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On the 10 May 2016 I commenced an investigation into the death of Dildar Shariff. The inquest into Mr Shariff’s death was heard on 7 September 2016. 4 CIRCUMSTANCES OF DEATH Mr Shariff died on 10 May 2016 at Fairfield General Hospital having been admitted following a cardiac arrest at his home address that day. He had had an unwitnessed fallen from a chair onto his kitchen floor on 8 May and attended at the Urgent Care Centre promptly following that fall. Neither a CT scan nor additional neurological observations were undertaken during that consultation. Mr Shariff attended the Urgent Care Centre again on 9 May with a history of head pain and recent vomiting. No CT scan was undertaken notwithstanding those symptoms and Mr Shariff was discharged home. On 10 May Mr Shariff was taken to hospital by attending paramedics where the presence of an intracerebral haemorrhage was confirmed. Mr Shariff was undergoing haemodialysis, which placed him at increased risk of haemorrhage. This was not appreciated by attending clinicians due to this not being referred to within the NICE guidelines for head injuries. 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: Evidence was given that patients who are undergoing haemodialysis or with significant uremia due to renal failure, such as Mr Shariff, are at increased risk of a haemorrhage and that this is not commonly known within the medical profession or referred to in the relevant NICE guidelines. This lack of awareness could create a risk that other deaths will continue to exist or occur in the future and whilst I am satisfied that the Trust have taken this matter very seriously, in that they have implemented appropriate measures to reduce the risk of this occurring in the future, I am concerned with the National picture as I am mindful that it may take some time for the significance of a head injury within patients with undergoing haemodialysis or with significant uremia due to renal failure to be incorporated into the NICE guidelines. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe each of you respectively have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 19 October 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely: The family of the deceased. I 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 from. 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. g Date: Signed:
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.
ki fib National Institutefor 10 Spring Gardens I I Health and Care Excellence London SW1A 2BU United Kingdom 3 October2016 +44 (0)300 323 0140 Ms Julie Robertson, Assistant Coroner H M Coroner’s Office The Phoenix Centre L Cpl Stephen Shaw MC Way Heywood OL1O 1LR Our ret: EH72969 Dear Ms Robertson, I write in response to the Regulation 28 Report into the death of Mr Dildar Shariff. I was very sorry to learn of Mr Shariff’s death You explain in your report that you consider there to be a lack of awareness within the medical profession that people undergoing haemodialysis, or those with significant uremia due to renal failure, are at increased risk of a haemorrhage. Subsequently, you’ve asked for the significance of a head injury in such people to be incorporated into NICE guidelines. We have noted the circumstances around Mr Shariff’s death and the concerns you have raised, in relation to our existing guideline on the assessment and early management of head injury (accessible from our website: www.nice.org.uk/cg1 76). Where our head injury guideline refers to “any history ofbleeding or clotting disorders” as a risk factor in the assessment of head injury, we do not list all the possible causes or scenarios, as it would be difficult to offer an exhaustive list. However, it is our view that it is widely known by clinicians that people with renal failure, including those with uremia or on haemodialysis, are at an increased risk of bleeding (especially where warfarin anticoagulation is used). Based on the circumstances you have described, we believe that at the second visit to the urgent care centre there was an opportunity for Mr Shariff to have had a CT scan (see recommendations in our head injury guideline that cover the criteria for performing a CT head scan in adults, specifically recommendations 1 .4.7 and 1 .4.8 which refer to risk factors of “more than I episode of vomiting” and “any history of bleeding or clotting disorders”, respectively). Alternatively, he could have been admitted for observation (see recommendation 1 .8, which sets out the criteria for www.nice.org.uk I nice©nice.org.uk admitting patients to hospital following a head injury, and includes “Continuing worrying signs (for example, persistent vomiting, severe headaches) ofconcern to the clinician” in the list). While we believe that our guideline does not need to be amended as a result of your report, your concerns have been logged with our guideline surveillance team, for their information when the guidance is next considered for update in 2017. Yours sincerely, ôE 1&y Sir Andrew Dillon Chief Executive
cake From the Lord Prior of Brampton D ep artm ent Parliamentary Under Secretary of State for Health (Lords) oes of Health co yr Ms Julie Robertson : Richmond House Assistant Coroner for Manchester North 79 waeenall H M Coroner’s Office SWIA 2NS Phoenix Centre, L/CPL Stephen Shaw MC Way Rochdale Tel: 020 7210 4850 OL10 ILR | 13 OCT 206 Thank you for your report of 7 September 2016, following the inquest into the death of Mr Dildar Shariff. I was very sorry to hear of Mr Shariff’s death in May 2016 and wish to extend my sincere condolences to his family. In your letter you consider there to be a lack of awareness among clinicians that an increased risk of haemorrhage is likely to occur in people undergoing haemodialysis, or those with significant uremia due to renal failure. You have therefore asked NICE to consider amending its relevant guidance for clinicians. Tam aware of NICE’s response and have noted its decision not to update its guidelines at the moment in relation to assessment and early management of head injury. I note that NICE has logged your report and the information will be looked at again when the guidance is next updated in 2017. Tam grateful to you for bringing the circumstances of Mr Shariff’s death to my attention. DAVID PRIOR So, orn
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