Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0362, written 14 Oct 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Oct 2016 |
|---|---|
| Reference | 2016-0362 |
| Deceased | Peter Keep |
| Coroner | Karen Henderson |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 THIS REPORT IS BEING SENT TO: 4. Sir Andrew Morris, Chief Executive, Frimley Park Hospital 2. TS Medical Director, Frimley Park Hospital CORONER lam Karen HENDERSON, assistant coroner for the coroner area of Surrey 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 INVESTIGATION and INQUEST On 18" August 2015 | commenced an investigation into the death of Peter John Keep, 82 years of age. The investigation concluded at the end of the inquest on 8th June 2016, The medical cause of death given was: 1a. Pulmonary Oedema 1b. Perforation of the right ventricle 1c. Insertion of pacemaker for heart block 2. My conclusion was: Died from a recognised complication of a necessary procedure CIRCUMSTANCES OF THE DEATH Mr Keep was a generally fit and well 82 year old man who was admitted into Frimley Park Hospital on 1* August 2015 following a fall at home. During his admission he was incidentally found to have Mobitz type 2 heart block and was recommended to have a pacemaker insertion. He consented and this was undertaken on the 4th August 2015. Prior to the procedure he was very anxious and | heard evidence he had a needle phobia. He was given 2.5mg ‘diazemuls’ (diazepam) intravenously and as he was still anxious was given a further 2.5 mg ‘diazemuls’ some ten minutes or so later. He was then given 2.5 mg diamorphine intravenously. During the initial part of the procedure | heard evidence that he was relatively settled. However, the pacemaker insertion was proving difficult and required multiple attempts without success. Mr Keep became uncomfortable and began waving his arms around during the time the pacemaker wires were being inserted. | heard evidence that the movement more likely than not would have increased the risk of ventricular perforation. He was given a further dose of 2.5 mg diazemuls. Shortly thereafter he ‘lost’ his airway and required a nasopharyngeal airway and high flow oxygen mask for an unspecified period of time. No consideration was given to abandoning the procedure or to ask for assistance. The pacemaker insertion continued and shortly thereafter Mr Keep had a precipitous fall in his blood pressure. He was found to have developed cardiac tamponade as a consequence of a perforation of the right ventricle from the attempted insertion of a pacemaker wire. This was treated with a pericardial drain which drained 500mis of blood. Mr Keep's blood pressure improved and a decision was made to continue with the pacemaker insertion with another cardiologist. Shortly after completion, Mr Keep suffered a pulseless electrical activity cardiac arrest and despite full resuscitation died later that night on the Intensive Care Unit in Frimley Park Hospital. i i H CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise for concern. In my opinion there is a risk that future death 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: 4. Inappropriate use of sedation and a lack of a sedation policy for cardiac electrophysiological procedures. 2. Anabsence ora lack of knowledge of a Trust policy for safe sedation outside the operating theatre environment, which could therefore not be considered or implemented. 3. An incoherent approach to sedation for procedures in the catheter Lab. with different clinicians using different drugs inconsistently e.g. use of an anxiolytic for discomfort. 4. No regular training for safe and appropriate use of anxiolytics and analgesics e.g. understanding their action and possible adverse effects or consideration of appropriate age related dosing. 5. Lack of an action plan for patients who do not tolerate the procedure. 6. Lack of an action plan as to who to call for assistance in circumstances when a patient's airway is lost or there is difficulty in placing a pacemaker wire. 7. Lack of understanding as to what observations are taken and are required during the procedure e.g. belief that the pulse oximeter measures respiratory rate | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation: Frimley Park Hospital NHS Trust has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date. |, the coroner, may extend this 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 opy of my report to the Chief Coroner and to the following Interested Persons: =’ (wife), a ee 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 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: 14" October 2016 SIGNED: Dr Karen Henderson
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.
Frimley Health oundation Frust Frimley Park Hospital Portsmouth Road Frimley Camberley Surrey GU16 7U) th 8" December 2016 Tel: 01276 604604 Or Karen Henderson HM Coroner HM Coroner’s Court Station Approach WOKING Surrey GU22 7AP Dear Dr Henderson RE: Mr Peter KEEP (Deceased) Thank you for your letter dated 14" October 2016 and the attached Regulation 28 Prevention of Future Deaths Report relating to the above named. We have reviewed the concerns raised following the Inquest into Mr Keep’s death and have outlined below what actions have been taken in an effort to improve the pathway for patients requiring sedation as part of a procedure, Contrary to the evidence heard at the Inquest, the Cardiology Department does have a guideline for intravenous conscious sedation which was in place at the time of Mr Keep’s procedure and which addresses many of the concerns raised through the Inquest including titration of drug doses, monitoring expected to be used, frequency of observations and training (copy enclosed). In the case of an emergency, as in any other interventional procedure, if the procedure proved to be difficult, help would be expected to be sought from other consultants. in the event of not achieving adequate sedation to allow a procedure to continue, the procedure should either be cancelled and re- booked with an alternative plan in place or help sought from an anaesthetist and appropriate resources in order to Increase sedation whilst maintaining safety. Emergencies due to over-sedation or cardio- respiratory compromise should be escalated via Trust’s normal route of calling ‘2222’ to activate the emergency team. Committee which will be chaired by Deputy Medical Director and Chief of Service for Anaesthetics. The Committee are currently reviewing and revising the Trustwide Guideline for intravenous Conscious Sedation of Adults addressing intravenous sedation in all clinical settings standardising the processes followed. The policy is in draft and going through the Trust's internal ratification processes together with the draft terms of reference for the Sedation Group (drafts of both attached). The Trust has also used your letter and ne . " an opportunity to relaunch the Trust Safe Sedation | | | The Cardiology team have discussed Mr Keep’s case through their internal Morbidity & Mortality processes to share the learning from this case and to ensure there is awareness of the expectations in terms of conscious sedation within the Cardiac Catheter Laboratory. The Trust is committed to patient safety and takes cases such as this very seriously and hope this is demonstrated in our response to the concerns raised. However, if | can be of any further assistance, please do not hesitate in contacting me. Yours sincerely Sir Andrew Morris OBE Hon FRCP Chief Executive Enc
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.