Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0489, written 18 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jul 2016 |
|---|---|
| Reference | 2016-0489 |
| Deceased | Khazna Khalaf |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
IN THE WEST YORKSHIRE WESTERN CORONER'S COURT IN THE MATTER OF: The Inquest Touching the Death of Khazna Jane Sara Khalaf A Regulation Report - Action to Prevent Future Deaths THIS REPORT IS BEING SENT TO: St Marien Hospital Trust, St. Marien-Hospital, Kunibertskloster 11-13, 50668 KoIn, GERMANY. 1 | CORONER Martin Fleming HM Senior Coroner for West Yorkshire Western 2 | CORONER’S LEGAL POWERS I make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 20 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On 3 December 2014 I opened an inquest into the death of J Khazna Jane Sara Khalaf who, at the date of her death, was aged 19 years old. The inquest was resumed and concluded on 6" July 2016. I found that the cause of death to be: - ja. Hypoxic-ischaemic encephalopathy 1b Cerebral oedema Ic Ecstasy/MDMA toxicity I concluded by way of a narrative as follows: On 12 November 2014 Khazna Jane Sara Khalaf was taken by ambulance to St Marien’s Hospital in Cologne, Germany, after ingesting ecstasy under circumstances which remain unclear. Upon arrival she was monitored until she suddenly collapsed. When she was transferred to Merheim Hospital, Cologne, Germany, she was found to have suffered a RT3589 1 cerebral oedema caused by hyponatraemia, a rare complication of ecstasy use, to which she succumbed and died on 20 November 2014. It is found more likely than not that there were several lost opportunities to monitor and treat her low sodium blood levels whilst at St Marien’s Hospital and that, had she been treated, it would have prevented her death. 4 | CIRCUMSTANCES OF THE DEATH Khazna Jane Sara Khalaf, a UK citizen was studying at Koln University as part of a student exchange. On the evening of 11 November 2014 she attended at the Odonien Nightclub during the carnival celebrations. The circumstances as to how she came to ingest ecstasy remain unclear, but after becoming unwell an ambulance was called at approximately 4.50am 12 November 2014 and when taken to St Marien Hospital in Cologne she was first examined at 5.03am, when records say she admitted to taking a pill of ecstasy. Subsequently she was monitored hourly until 9.20am when she collapsed unresponsive. At 10.30am she was transferred to Merkheim Hospital, where CT head scans revealed that she had suffered a cerebral oedema such that it brought about hypoxic ischaemic encephalopathy as a result of ecstasy toxicity. Thereafter she very sadly succumbed and died on 20 November 2014. 5 | CORONER'S CONCERNS During the ¢ inguest I noted the full contents of the report provided = could not attend to give oral evidence, and it was his view that upon Jane's initial arrival at the hospital she did not present with sufficient clinical signs to justify a blood sample to determine serum sodium levels, and that there was no evidence to suggest that an early blood sample would have led to a much longer survival. This was at variance to the oral evidence I heard from HE an independent expert in Anaesthesia and Intensive Care Medicine, and I accepted his view that had an early blood sample been taken prior to her collapse, it would have identified her low sodium levels such that she would have received effective treatment that would on the balance of probabilities have prevented her death. The MATTER OF CONCERN is as follows. — e The effectiveness of local protocols and the sufficiency of existing hospital guidelines alerting clinicians to the risks of ecstasy toxicity, the symptoms and signs it might present. e To consider the appropriateness of a clinical protocol which RT3589 2 provides structure to the initial decision to intervene or simply monitor, and guidance on what that monitoring should consist of (and when to be concerned and reassess the initial decision). 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that St Marien’s Hospital Trust, Cologne, Germany has the power to take such action. © 7 | YOUR RESPONSE | You are under.a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 | COPIES Ihave sent a copy of this report to: ° (father) @ er Coroner 9 | DATED this 18™ July 2016 I R Feu M.D. Fleming Senior Coroner RT3589 3
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.