Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0142, written 30 Apr 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Apr 2017 |
|---|---|
| Reference | 2017-0142 |
| Deceased | Ahsiyah Bibi |
| Coroner | Emma Brown |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Heart of England NHS Foundation Trust |
| 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Heart of England NHS Foundation Trust
CORONER
tam Emma Brown Area Coroner for Birmingham and Solihull
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 30/12/2016 | commenced an investigation into the death of Ahsiyah Bibi. The investigation concluded
at the end of an inquest on 27th April 2017. The conclusion of the inquest was Natural causes.
CIRCUMSTANCES OF THE DEATH
The Deceased passed.away in Birmingham Heartlands Hospital during the afternoon of the 22nd
December 2016. She had been admitted shortly after midnight with reduced consciousness. It was
evident in the early hours of the morning that she was suffering acute renal failure. She did not respond
to treatment and was not a suitable candidate for dialysis and was declared deceased at 16:10. During
the course of her treatment she was given an overdose of insulin — this is unlikely to have contributed to
her death. There was also a delay in the commencement of treatment for high potassium but this is also
unlikely to have contributed to Mrs. Bibi’s death.
Based on information from the Deceased’s treating clinicians the medical cause of death was determined
to be:
1a Acute Kidney Injury of unknown origin.
2 Congestive cardiac failure, ischaemic heart disease, obstructive sleep apnoea, diabetes
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. When reviewing Mrs. Bibi at o2:14 did not have the results from an arterial blood
gas performed by the nursing team at 01:52 which demonstrated high potassium therefore
treatment for high potassium was not commenced until approximately 04:00 when the high
potassium had been identified. tt was the evidence of Han hat from time to
time the hard copy blood gas results do get separated from the records and if the Clinician
doesn’t know the test has been undertaken they will have no reason to go and source the
results.
2. At04:00 a drug error was made in the prescribing and dispensing of Actrapid insulin for
hyperkalaemia: Mrs. Bibi was prescribed a 50 unit dose instead of a 10 unit dose, the error was
identified when she had received 20 units and the infusion was stopped. The evidence of
HB who prescribed the insulin was she knew the Trust’s protocol and standard treatment to
be a dose of 10 units but made a mistake. It appears from investigations carried out by
that the two members of the nursing staff who dispensed the dose did not check the dose.
Professor Hanif, Consultant in Diabetes, gave independent expert evidence that in his view there
is a risk of inappropriate prescribing of insulin in the management of hyperkalaemia because
clinicians are more commonly called upon to prescribed a 50 unit does for Hyperglycaemia.
Therefore in his opinion a system is required to avoid error in cases of hyperkalaemia
agreed that the fact she more commonly prescribes a 50 unit does of insulin for hyperglycaemia
probably did explain her error.
3. HE <vidence was that although he has investigated the insulin prescribing error and it
has been discussed with the individuals involved there has not been a Trust wide review of the
risks of this occurring again and consideration of a system to reduce the risk of error. The
problem of missing blood gas results was identified by be not considered for further
action within the department or across the Trust.
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 27*
June 2017. |, 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: the family
of Mrs. Bibi.
| 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.
30/04/2017
Signature
Emma Brown Area Coroner Birmingham and Solihull
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