Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0270, written 10 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Aug 2017 |
|---|---|
| Reference | 2017-0270 |
| Deceased | Claire Medhurst |
| Coroner | Patricia Harding |
| Coroner area | Mid Kent and Medway |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Medway NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Medway NHS Foundation Trust CORONER 1 I am Patricia Harding Senior Coroner for Mid Kent and Medway 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 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 17/03/2017 I commenced an investigation into the death of Claire Joan Elizabeth MEDHURST. The investigation concluded at the end of the inquest. The conclusion of the inquest was an open conclusion with how when and where the deceased came by their death being recorded as: Claire Medhurst died from the consequences of fulminant liver failure caused by a polypharmacy overdose on 24th February 2017 at King’s College Hospital liver unit where she had been transferred after presenting to Medway Maritime Hospital on 27th January 2017. That she had acute liver failure on admission as a result of the ingestion of an unknown quantity of paracetamol was not recognised or treated for some six hours by which time her condition had significantly deteriorated. Claire Medhurst had previously been admitted to Medway Maritime Hospital on 22nd January 2017 following a polypharmacy overdose which was treated and resulted in a discharge as medically fit on 25th January 2017. Although in taking the first overdose she intended to end her life, her intention in ingesting further paracetamol cannot be determined from the evidence. 4 CIRCUMSTANCES OF THE DEATH On 22nd January 2017 Claire Medhurst aged 37 was admitted to Medway Maritime Hospital having taken a poly pharmacy overdose the significant components of which were paracetamol and ibuprofen. She was provided with n-acetyl cysteine infusions in accordance with national guidance and was discharged on 25th January 2017 when medically fit, blood tests at the conclusion of treatment showing normal liver function. She underwent a mental health assessment prior to discharge which established that her intention in taking the medication was to end her life and whilst she still had suicidal thoughts she had no plans to end her life. As a result of this and the fact that she was prepared to engage with the mental health team in the community, she returned home. On 27th January 2017 she was readmitted to Medway Maritime Hospital with abdominal pains. She denied having taken further medications. A blood sample taken shortly after her admission revealed grossly abnormal liver function and a toxic level of paracetamol. The clinicians were not alerted to the results by the laboratory, nor did a clinician review the results when reported. As a result there was a delay in treatment with n-acetyl cysteine of some six hours by which time her condition had significantly deteriorated. She was admitted to the Intensive Treatment Unit for stabilisation before being transferred to King’s College Hospital Liver Unit on 28th January 2017 where despite supportive measures being provided she further deteriorated and died on 24th February 2017. The medical cause of death was established to be: 1a b c II Multi Organ Failure Fulminant Liver Failure Polypharmacy Overdose Hepatic Steatosis 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. – [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The discharge process on 25th January 2017 did not include any cautionary advice as to the further use of medications such as paracetamol or ibuprofen as an analgesic particularly when Claire Medhurst had been experiencing headaches shortly before discharge and had been prescribed ibuprofen (2) The treating clinicians did not receive an alert from the haematology laboratory for the abnormal results for ALT and toxic levels of paracetamol 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Medway NHS Foundation Trust 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 by 9th October 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Next of Kin, Kent & Medway NHS and Social Care Partnership Trust. I have also sent it to Care Quality Commission who may find it useful or of interest. 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 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. 9 10/08/2017 Signature: Patricia Harding Senior Coroner Mid Kent and Medway
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.
INHS| Medway DIRECTOR OF NURSING OFFICE NHS Foundation Trust Direct line: Ms Patricia Harding Medway Maritime Hospital Senior Coroner for Mid Kent and Medway Windmill Road Kent Register Office Gillingham The Archbishop's Palace, Palace Gardens Kent Mill Street ME7 5NY Maidstone, Kent ME15 6YE 6" October 2017 Dear Ma’am Re: Regulation 28 Report to Prevent Future Deaths — Claire Medhurst (deceased) We refer to your report issued following the inquest touching upon the death of Claire Medhurst dated 10 August 2017 pursuant to Regulation 28 of the Coroner's (Investigations) Regulations 2013. The follow is our response in relation to the matters of concerns raised: The Discharging Doctor did not provide any cautionary advice as to further use of analgesics such as paracetamol or ibuprofen The Trust accepts that more should be done to ensure that patients presenting at the Emergency Department (ED) who have had an overdose are provided with appropriate information about paracetamol overdose and precaution around the use of other drugs that contains paracetamol. The action taken with the learning from this case is described as follows: 1. All key relevant staff will receive feedback via the appropriate staff meeting. These meetings are already scheduled and all clinicians within the Emergency Department and the acute assessment areas will receive the information through the staff briefings. All staff will be given an overview of the case and the importance of providing essential information to patients and their families on the use of drugs containing paracetamol and ibuprofen will be detailed. 2. The importance of providing essential information about paracetamol overdose and precaution around the use of other drugs that contains paracetamol upon discharge has been discussed in the Emergency Department daily safety huddles to ensure that all members of staff are aware of the importance of providing such information. 3. Staff are required to record the advice given to patients in the patients’ medical notes. A spot check audit will be undertaken and this will take place regularly in order to ensure a consistent change in practise can be evidenced. The results from the first of these audit results is attached as appendix 1. The audit will occur monthly until the Directorate Governance Committee is assured that this practice is fully embedded and sustained. Best of care Best 4. An information leaflet has been developed and will be ratified via the Directorate Governance Board on 6" October 2017. Once ratified, leaflets will be printed and available in the ED on 23 October 2017. Patients will receive this information as part of their medical management and discharge plan. Staff will include in their documentation that a leaflet has been given and fully explained to the patient. Once implemented, this will be included in the monthly audit programme. The patient paracetamol overdose leaflet is attached as appendix 2. 5. All patients with an overdose must be reviewed by the nurse in charge of the department/acute assessment wards prior to their transfer or discharge. This will ensure that the patients’ medical management and discharge plan has been fully implemented. In the case of paracetamol overdose this has been included in the revised standard operating framework (appendix 3). The Trust adhere to national poisons guidance and access to this is available to all staff working in the ED/acute assessment areas. The treating clinician did not receive an alert from the haematology laboratory for the abnormal results for ALT and toxic levels of paracetamol. An investigation into the serious incident was conducted by the head of the biochemistry and pathology department and immediate actions implemented following the outcome of the investigation. Summary of investigation ¢ On27"™ January 2017 blood samples were taken from the patient and a request was made to the laboratory at 17:23 hours to test for U&E, liver function, CRP and amylase. At 18.25 hours the clinician in the Emergency Department telephoned the laboratory to request a further test for paracetamol/salicylate levels. The sample was analysed, authorised and available to clinicians in the Emergency Department on the ILAB web system at 19:00 hours. The investigation concluded that this process was managed to the expected standard. e There are existing protocols in place with regards to the actions required by staff when ALT levels are outside the safe limits. In the case of Clare Medhurst, the ALT level was above the limit and the paracetamol level was also above the SBAR limit. This required the technician to telephone the requesting clinician with the results. e There was no evidence in laboratory records that either of these results were communicated to the requesting clinician. e The investigation included interviewing the member of staff that received and processed the specimen. On examination of the records it highlighted the SBAR form was not completed in accordance to the SBAR reporting protocol. The Trust SBAR system to bleep critical results requiring immediate action to doctors is attached as appendix 4. e The analyser repeat log for that day was available but there was no record of the actions taken given the abnormal blood result. Best of care Best Actions taken to address issues raised are: 1. On 4" September 2017, the outcome of the investigation was shared with the staff involved in the incident. The member of staff was able to conclude a reflective practice and has demonstrated learning from this incident and that their usual standard of work is in line with Trust policy. 2. As aresult of this incident an algorithm has been written to add a ‘paracetamol to phone’ trigger test. Furthermore, on the first occurrence of an ALT level outside of the safe range (>825), the system flags a reminder to the laboratory staff to telephone it through to the requesting clinician. This flagging system was implemented on 5'" September 2017 and applies to all tests were the levels are outside of the safe range and require immediate actions by a clinician. The Biochemistry Department ‘when to telephone a result’ document is attached as appendix 5. 3. An audit will be conducted in October 2017 to measure compliance with SBAR and the associated protocols, and ensure Trust procedures is being adhered to. | have also taken the opportunity to share with you in appendix 6 the Trust serious incident report and integrated action plan which is currently in draft form awaiting CCG approval. Yours faithfully Director of Nursing @) Best of care
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