Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0069, written 22 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Mar 2017 |
|---|---|
| Reference | 2017-0069 |
| Deceased | Michael Uriely |
| Coroner | Shirley Radcliffe |
| Coroner area | London Inner (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO 1. Professor Sir Brian Keogh National Medical Director NHS England Rm 504 Richmond House Whitehall London SW1A 2NS 2. Professor lan Cummings OBE Health Education England 1* Floor Blenheim House Duncombe Street Leeds LS1 4PL 3. Sir Andrew Dillon CBE National Institute for Clinical Excellence Midcity Place 71 High Holborn London WC1V 6NA 1 | CORONER 1am Dr Shirley Radcliffe for the coroner area of Inner West London 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 On 15" and 16" March 2017 an inquest was held touching the death of Mr Michael Uriely and concluded on 16"" March 2017 with a narrative conclusion. 4 | CIRCUMSTANCES OF THE DEATH Circumstances of death Michael Uriely was diagnosed with asthma at the age of 2 % years. His asthma started to deteriorate during 2014 when he needed six courses of oral prednisolone for asthma attacks and then further during 2015. In the seven months before Michael’s tragic death, his asthma, was uncontrolled, difficult to control, and probably severe. Furthermore, there were a number of missed opportunities by health professionals during these seven; had these been managed differently according to the NRAD recommendations and the BTS/SIGN guidelines, the outcome might have been altered. From the medical records, it seems that no single clinician took overall responsibility for ensuring continuity and the ongoing management of Michael’s asthma; there was no evidence of an ongoing coherent plan for the management of this child’s chronic ‘at- ‘risk’ condition. Despite Michael’s high risk status, he was not referred to or seen by a specialist respiratory paediatrician, which was a clear recommendation in the NRAD report. CORONER’S CONCERNS After reading the letter from the LFB | share their concerns in relation to potential inadequacy of fire risk assessments. The MATTERS OF CONCERN are as follows. — 1) The care management and treatment of this child during his final year of life with an exacerbations of asthma was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning him to the care of his family. 2) There was:- i) No co-ordinating record of these occasions. ii) No analysis of the acute episodes in context with his chronic asthma condition. iii) No appreciation of the underlying severity and analysis of the level of medication prescribed. ; iv) No appreciation of the risk factors of near fatal or fatal asthma evident in this child. v) No appreciation of the deteriorating nature of his asthma. 3) Despite the presence of a significant number of health care professionals involved in his care, no single individual assumed management for his care overall. In the absence of no one individual assuming responsibility for his care there was no plan directed towards his long term management and care identifying the chronic nature of his condition, seeking a sustained and balanced level of treatment, control. In and of itself the death of this child demonstrates a profound and woeful indication of the lack of understanding of how this condition, its recurring nature can and should be managed by someone with the proper training and understanding of this chronic respiratory disease. The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak , expiratory flow/ PEF or spirometry) was not always measured when indicated; his medication was not optimised despite poor control; current asthma control was not always assessed using one of the tests recommended; Michael’s frequency of use of relievers was never recorded; inhaler technique checking was not recorded; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael. 7) Two further areas of concern presented, inter related but independently significant and critical in this matter: Michael’s mother readily presented her child for care in and out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and = ° 6 A treatment. B) Evidence was also received of the failure to refer this child to a tertiary respiratory service which may have resulted in a different approach to his treatment which may have prevented his death, by: i) The general practitioners who failed to recognise the severity of his condition and that referral to a tertiary unit could have been considered. ; ii) The A&E and inpatient service at the local hospital. 8) Michael was never formally referred to a tertiary respiratory service. 9) The National Review of Asthma Death (NRAD) 2011-2014 was published in a report entitles ‘Why Asthma Kills’ on the 6" May 2014. The Review’s evidence based conclusions and recommendations exemplify and underline the same missed opportunities and poor practice which led to Michael’s death. 10} Following the NRAD recommendations published in May 2014, and widely publicised in local and national media, and GP Press, Michael's high risk status was not recognised which should have prompted a referral to a difficult or severe asthma service run by a paediatric respiratory specialist. 11) The conclusions of the Review would not of themselves have impacted on the events leading to Michael’s death but in the context of seeking to avoid future deaths, the Review and the evidence of Michael’s Inquest identify a need by both national and local agencies to revisit the recommendations of the Review, the formal substance of training identified as appropriate for the care and treatment of Asthma, the nature of that disease and the strategies essential for the long term management, care and prevention of uncontrolled re-occurring attacks. 12) It is right to acknowledge that the local Trust in this matter have responded to the criticism directed towards them and sought to identify better practices for the future, their experience needs to be shared by and with other medical care professionals on a continuing bases, and their resolve to do so, evidence of their commitment that lessons have been learned. 13) There are undoubtedly resource issues implicated in this matter but a demonstration of resolve and an effective lead given by the Department of Health and those involved in the provision of Health Service guidance and education nationally would demonstrate a universal resolve to standardise the care of chronic asthma patients and to make paediatric asthma death a “never event”. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. lam of the firm opinion that if the recommendations of the National Review for Asthma Deaths, published in 2014, had been locally disseminated and implemented would have prevented the death of MU. Since the death of MU there have been at least a further seven child deaths in London due to asthma and certainly many more throughout the NHS England. lam aware of the Regulation 28 that was issued following the inquest of Tamara Mills (died April 2014) issued in 2015 which highlighted the concerns of Her Majesty's Senior Coroner Terrance Carney for Gateshead & South Tyneside. There has been.a body of work published by NHS England over the last seven years, which pertain to the body standards and recommendations to improve the care of children and adults with asthma and prevent deaths. | have also seen the response to the regulation. Fifteen months on, | would like to enquire what is the process and timelines by which the following recommendations from NRAD 2014, which were identified in the Regulation 28 will be implemented across NHS England. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by igh May 2017. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons : . Consultant in Respiratory & General Paediatrics Cambridge University Hospitals (email) Kenton Bridge Medical Centre 155-175 Kenton Road Kenton HA3 0YX | 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. . 22" March 2017 (a . Dr Shirley A Radcliffe HM Assistant Coroner, Inner West London, Westminster Coroner’s Court, 65, Horseferry Road, London. SW1P 2ED.
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.
NHS OFFICIAL . England Dr Shirley Radcliffe NHS England HM Assistant Coroner Skipton House Inner West London 80 London Road Westminster Coroner's Court London 65 Horseferry Road SE1 6LH London : SW1P 2ED england.medicaldirector@nhs.net May 2017 Dear Dr Radentfo 5 barley Re: Regulation 28 Report to Prevent Future Deaths - Michael URIELY (died 25.08.15) Thank you for your Regulation 28 Report which was received on Wednesday 29 March 2017 following the inquest into the sad death of Michael rely, | would like to express my deep sympathy to Michael's family. Asthma deaths in children and young people are rare and have reduced substantially over the years. Nonetheless, each individual case is a tragic loss and often associated with preventable factors. In this particular case, it appears Michael's condition was not managed in accordance with the published asthma guidelines, specifically to treat asthma as a as a long term condition rather than a series of episodic incidents. Sadly this case has many similarities to the death of Tamara Mills as you have also noted in your report. We will endeavour to do all we can to prevent any further asthma related death, especially in children and young people, and to ensure that the NHS appropriately manages asthma care across England. As you are aware, most asthma care is delivered in Primary Care by General Practitioners (GPs). Most Clinical Commissioning Groups (CCGs) have been delegated the exercise of primary medical services by NHS England so that they can commission care according to the need of their population. GPs and other Doctors who treat asthma have a professional responsibility to have regard to set clinical guidelines and to refer to a respiratory specialist where deemed appropriate. Apart from the recommendations of the 2014 National Review of Asthma Deaths, there are established evidence-based asthma guidelines from BTS/ SIGN’ which have recently been updated. These are promoted to primary care through the Primary Care Respiratory Society (PCRS). NICE has produced a Quality Standard 1 https://www.brit-thoracic.ora.uk/standards-of-care/quidelines/bissian-british-quideline-on-the- management-of-asthma/ Health and high quality care for all, now and for future generations OFFICIAL. (QS25”) and is in the process of developing guidelines for the Diagnosis and Monitoring of Asthma and also for the Management of Stable Asthma in Adults and Children. It is expected that these will be published later this year. NHS England is actively working to improve asthma care in children, We have listed below some of the on-going key areas of work in response to the matters of concern listed in your report and to also serve as an update on the actions we set out in response to the death of Tamara Mills. 1. In 2014 NHS England set up National Paediatric Asthma Collaborative (NPAC)? , partly in response to NRAD, to bring together a wide range of clinicians, commissioners and voluntary sector organisations to work together on improving care and support for children with asthma. It was successful in reviewing existing services and their effectiveness, highlighting and sharing good practice, and outlining deficiencies at a national level. This work has been beneficial to a wide range of subsequent workstreams listed below. 2. NHS England commissioned Health Quality Improvement Partnership (HQIP) to scope a national audit on asthma. As a result, HQIP have taken forward the National Asthma Audit Development Project’, delivered by the Royal College of Physicians. This is a study to assess whether or not a National Asthma Audit would be feasible, what could be included and how it could be organised. There are some pre-set aims for the feasibility study, one of which is to ensure the scope considers both children and adults. 3. The development of the e-learning pack, E-asthma® was commissioned from Education for Health via Health Education England (HEE) and NHS England/ . NPAC. This is an interactive asthma education resource for healthcare professionals of all disciplines. It aims to help to improve the diagnosis and management of asthma as a long-term condition for both children and adults. It is an entry level program which is free for all healthcare professionals and has been designed so that it can be audited by a health care provider, such as a hospital or CCG. 4. NHS England has supported the development of a severe paediatric asthma database to collect vital information that will help support improvements in severe asthma ‘care in the future, This has helped develop the Paediatric Severe Asthma CQUIN. 5. Launched in December 2016 the Paediatric Severe Asthma CQUIN was designed to support services at a tertiary level and to mirror the adult provision of care that had been achieved through céntral commissioning. The CQUIN is currenily being trialled in London across the 5 larger secondary and tertiary care units as well as several other tertiary centres and managed by Dr Louise Fleming at the Royal Brompton Hospital. 2 httos:/Awww.nice.org.uk/quidance/gs25 3 http://www. respiratoryfutures.org.uk/programmes/national-paediatric-asthma-collaborative/ a hitos:/Awww.replondon.ac.ul/projects/national-asthma-audit-development-project ° http/learning.wm_hee.nhs.uk/node/163 Health and high quality care for all, now and for future generations OFFICIAL 6. We have developed a Quality Payments Scheme for community pharmacy’ to encourage community pharmacists to systematically identify patients who receive more than six bronchodilator inhalers in six months without any corticosteroid inhaler and refer them for asthma review. There are over 11,600 pharmacies in England and we will be evaluating this scheme to look at the impact. This element of the Quality Payments scheme was incorporated as a direct result of the NRAD recommendations. 7. We continue to explore with clinicians how a Best Practice Tariff would help incentivise the provision of best practice care for children with asthma. A best practice tariff (BPT) is where, rather than setting the price for a service at the average price, we link the payment a provider receives to the achievement of best clinical practice. Our initial assessment is that the information needed to enable us to link payment to the characteristics-of best clinical practice is not currently collected centrally. However, we are still pursuing the possibility of a BPT and working with NHS Digital to ensure we can collect the appropriate data. 8. Through the NHS RightCare’ programme we have included an indicator on emergency admissions to hospital for children with asthma in the asthma - pathway within the ‘Where to Look pack’. This pack is a comprehensive intelligence data pack which aims to give CCGs and local health economies practical support In where to focus their efforts in order to improve care and reduce unwarranted variation. As part of this work we are actively supporting and working with 38 CCGs across the country directly on respiratory conditions some of which are asthma specific. Sharing and coordinating care records for all illnesses within a complex NHS has always been a challenge. As the NHS responds to these challenges we are finding more and more A&E departments can access primary care records, To change and improve asthma care across organisations, NHS England is also working in partnership with CCGs in London to transform care via the Healthy London Partnership Collaborative (HLP) ®. This collaborative brings together health, social care, local government and other partners to transform care across the capital. Specifically for asthma the following work has been undertaken by HLP; * The development of London Paediatric Asthma Standards® was published in 2015 and sets out a minimum standard of asthma care for children and young people across London. They have been developed around 11 key areas including primary, secondary and tertiary care, pharmacy, schools and transition. § hitps://www.england.nhs.uk/commissioning/primary-care-comm/pharmacy/framework-161 8ipap/, * httos://www.england nhs. uk/rightcare/ * httos:/Avww.myhealth.london.nhs.uk/healthy-london-partnership > http://www tondonscen.nhs.uk/wo-content/uploads/2015/07/cyp-asthma-stds-062015.pdf_— Health and high quality care for all, now and for future generations OFFICIAL 9. The London paediatric asthma toolkit” has been created to support healthcare professionals, schools, parents, carers and children and young peopte to improve care across the system. It advises on access, evidence, defines roles and responsibilities, techniques, plans and pathways. It also includes an online learning hub for pharmacists’ to assess support including actively promoting good inhaler techniques, which can support direct referral from primary care into community pharmacy and to enable care reviews. The tool has been endorsed by the Royal College of General Practitioners (RCGP), Royal College of Paediatrics Child Health (RCPCH) and by Asthma UK. . 10.A public awareness campaign. As you have noted in your report, clearer messaging on the management of asthma to patients, parents, carers and - health professionals is vital. This need was also identified In the Healthy London Partnerships (HLP) work. They are currently working on a simple public awareness campaign. This will be trailed and assessed in London with the view to roll this out national if successful. 11. The development of a hand held patient app. Although still in the design and development stage, this app may enhance the existing system and allow care records to be shared more easily. In addition, within your letter you also ask about the possibility of paediatric asthma death being classified as a ‘Never Event’. This was reviewed by the National Clinical Lead for children and young people and by clinical advisers with in the HLPs. They concluded that in its strictest definition, not all asthma deaths are preventable and therefore ‘Never Event’ status would be medically incorrect. For the NHS a ‘Never Event relates to serious incidents that are wholly preventable as guidance or safety recommendations provide strong systemic protective barriers which are available at a national level and should have been implemented by all healthcare providers. Never Events include incidents such as; wrong site surgery, retained instrument post operation or, for example, wrong route administration of chemotherapy. However, we strongly support the principle that each paediatric asthma death should be a Serious Incident and have a multi-level cross system review. NHS England has undertaken a review of children and young people deaths in London as a result of asthma. This is a collaborative piece of work with the Child Death Overview Panels, (CDOP)"" - which bring together a wide range of local bodies such as local authorities, the police, social care, health with the purpose of reviewing each child death ~ to produce a systematic template for asthma deaths (akin to an asthma death proforma), to provide clinical expertise to investigate all asthma deaths in future. Our aim is that the learning from this review will be shared and implemented across the country. : With regards to GP training, NHS England is unable to amend the content of the GP’ training curricula, but we will relay these concems to Health Education England (HEE) to ensure that professional routes are used to advise GPs and other doctors ad https //www.myhealth Jondon.nhs.uk/healthy-londen/chiidren-and-young-people/london-asthma- toolkit * inttps://www.gov.uk/government/publications/working-together-to-safequard-children--2 Health and high quality care for all, now and for future generations OFFICIAL delivering against Asthma care guidelines. We will also advise CCGs to make all GPs aware of the free E-asthmas training program as mentioned above and any asthma related practice software add-ons such as the PRIMIS Asthma Care Quality Improvement Too!" to alert them to patients who might be at risk from over prescription of bronchodilators, NHS England will continue do more to ensure that CCGs and GPs are aware of the clinical and quality guidelines around asthma care especially for children and young people. To support this we will: 1. Share learning and support tools developed by the Healthy London Partnership collaborative and others, such as the E-asthma toolkit, standards. and clearer messaging. These will be shared across the whole of the NHS commissioning landscape to ensure CCGs take active measures in asthma management. 2. Communicate to CCGs & GPs on using the most up to date asthma guidelines and recommendations from the NRAD to aid the development of appropriate asthma patient care pathways. We will also advise CCGs to encourage GPs to take up available free asthma risk alert software. 3. Continue to explore commissioning mechanisms, such as the implementing a Best Practice Tariff, CQUIN development and RightCare programme initiatives to better incentivise improved commissioning of asthma care. | note that your Regulation 28 report was also issued to HEE and to NICE. | shall liaise with both organisations in relation to implementing asthma guidelines so that the NHS minimises the risk of future deaths in this area of healthcare. | will also contact the NHS Trust in question to understand better their lessons learnt and ensure that this shared regionally. Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, Professor Sir Bruce Keogh KBE, MD, DSc, FRCS, FRCP National Medical Director NHS England hr hitpdwww.nottingham.ac.uk/primisiocls-audits/tools-audits'asthma.aspx Health and high quality care for all, now and for future generations
NIC National Institute for Health and Care Excellence London 10 Spring Gardens SW1A 2BU United Kingdom 11 May 2017 +44 (0)300 323 0140 Dr Shirley A Radcliffe Inner West London HM Assistant Coroner J Westminster Coroner’s Court Gh ~ H M Gofoner’s Office 65 Horseferry: ‘Road Lofidon " SW1P 2ED Our ref: EH80325 Dear Dr Radcliffe, | write in response to the Regulation 28 Report into the death of Mr Michael Uriely. | was very sorry to learn of Mr Uriely’s death. __We have considered the circumstances around Mr Uriely’s death and the concerns you have raised. We have produced a quality standard on asthma that covers diagnosing and managing asthma in adults and children (aged 12 months and over). NICE quality standards describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements. They draw on existing guidance, which provides an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement. Our quality standard makes clear (on page 8) that services should be commissioned from and coordinated across all relevant agencies encompassing the whole asthma cate pathway; that an integrated approach to provision of services is fundamental to the delivery of high quality care to adults, young people and children with asthma; and that’all healthcare professionals involved in diagnosing and managing asthma in adults, young people and children should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Our quality standard includes the following statements that appear most relevant to the circumstances you've described: Quality statement 3: People with asthma receive a written personalised action plan www.nice.org.uk | nice@nice.org.uk e Quality statement 5: People with asthma receive a structured review at least annually. e Quality statement 9: People admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge. e Quality statement 10: People who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within 2 working days of treatment. e Quality statement 11: People with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service, to accurately diagnose their asthma, exclude alternative causes of persistent symptoms, manage comorbidities, confirm adherence to therapy and ensure they are receiving the most appropriate treatment. These quality statements are based on the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network’s (SIGN) British guideline on the management of asthma (SIGN clinical guideline 153), which is a NICE accredited guideline. In addition to our published quality standard on asthma, we are currently developing guidelines on the diagnosis and monitoring of asthma and on asthma management. However, the scope of these guidelines do not cover managing severe asthma or acute asthma attacks. Both guidelines are due to be published in October 2017. Once published, our quality standard will be reviewed and- updated where appropriate, in line with our recommendations. We will be producing tools and resources to help support the NHS to implement the recommendations, and we are working with NHS England on implementation of the guidance. Yours sincerely, SC Sir Andrew Dillon Chief Executive
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