Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0327, written 28 Jul 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Jul 2017 |
|---|---|
| Reference | 2017-0327 |
| Deceased | Pamela Keech |
| Coroner | Hassan Shah |
| Coroner area | Northamptonshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Health Education England 2. Joint Royal Colleges Ambulance Liaison Committee 3. British Renal Society 4. Renal Association 5. The Vascular Access Society of Britain & Ireland 1 CORONER I am Mr Hassan Shah, Assistant Coroner, for the coroner area of Northamptonshire. 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 7 July 2015 I commenced an investigation into the death of Pamela Keech, aged 82 years. The investigation concluded at the end of the inquest on 9 June 2017. The conclusion of the inquest was as follows: Pamela Keech was declared dead at 07.03 hours on Tuesday 7 July 2015 at Elm Bank Care Home, Northampton Road, Kettering. She died as a result of a catastrophic bleed from her haemodialysis graft site, a rare but recognised complication of this life saving treatment. 4 CIRCUMSTANCES OF THE DEATH Pamela Keech was diagnosed with end stage renal failure in 2005. She required haemodialysis as life-saving treatment. The gold standard for delivery of haemodialysis is via an arterio-venous fistula, which is typically formed in the patient’s arm. However, assessments showed that Mrs Keech’s vasculature would not support such a fistula, an upper limb fistula having previously failed in 2009. Various alternatives were utilised to administer haemodialysis until a femoro-femoral graft was formed in Mrs Keech’s leg in 2011. In 2014, Mrs Keech was prescribed the anti-coagulant Warfarin. In January 2015, Mrs Keech underwent a thrombectomy and a jump graft was fitted. On 26th June 2015, Albumin level was low, an indicator of poor prognosis in haemodialysis patients. On Saturday 4th July 2015, Mrs Keech underwent dialysis. Both needle sites were red and leaking fluid; there was a slight bleed at the end; her leg was swollen (not unusual for Mrs Keech); she had a low Albumin level; there was no clear sign of infection (although results that became available on 8th July 2015 confirmed that she was MRSA positive at the access site). On Sunday 5 July 2015, Mrs Keech was conveyed to hospital by ambulance as she was bleeding from her leg in the location of her graft site and was reportedly “covered in 1 blood”. She was seen in the Accident and Emergency Department where the treating doctor incorrectly believed the bleed was as a result of an operation Mrs Keech had undergone some months previously to treat a fractured neck of femur. There was an open puncture wound on the anterior surface of the thigh which had a trickling bleed during 5 minutes of examination. However, when Mrs Keech’s daughter arrived, she explained the bleed had originated from Mrs Keech’s graft site and that bleeding following dialysis was not unusual for Mrs Keech. This reassured the doctor, who discharged Mrs Keech given that all of her observations were within normal parameters, save slightly raised CRP (a non-specific marker of inflammation). That first bleed stopped and was not catastrophic. The doctor accepted with the benefit of hindsight that Mrs Keech should have been referred for renal/surgical review, however, this was not known in the department at that time. On the evening of 5 July 2015 Mrs Keech’s care home contacted the ambulance service as they had noted a further bleed from Mrs Keech’s leg. Mrs Keech was reviewed by an Emergency Care Practitioner who found her to be calm, conscious, alert, breathing, capillary refill less than 2 seconds, normal colour with a history of bleeding. Blood pressure was 170/88, slightly high but within an acceptable range. Temperature was 37.1, slightly raised but not of concern. The Emergency Care Practitioner noted a wound of 1cm on Mrs Keech’s leg but it was not clear as to where the wound was. In all likelihood it would have been from the graft access site but the evidence was not clear. The Emergency Care Practitioner knew Mrs Keech had been discharged earlier with a fistula haemorrhage. Observations were normal and the bleeding had stopped, with only a small amount of blood loss. The Emergency Care Practitioner decided that treatment was not required at hospital so provided a bandage and left advice that if a further bleed occurred again then 999 should be contacted. This was a second bleed and was not catastrophic. On Monday 6 July 11.30am Mrs Keech was attended to by an Occupational Therapist at the care home. She noted that the bandage had dry blood on it but it was not clear where the blood had come from. Observations were within the normal range. This was a third mini bleed from the leg and did not prove fatal. At 6.15am on 7 July 2015 Mrs Keech was found unconscious in her bed with a large amount of blood loss from her leg. Mrs Keech was declared deceased at 7.03am. A post mortem examination found that she had died as a result of a catastrophic haemorrhage from the graft site in her leg. 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. – (1) I heard evidence that there is no National Guidance on how to predict and manage a fatal graft/fistula haemorrhage (2) I heard evidence that the risk of developing a fatal haemorrhage from a fistula/graft site is not part of the training requirement for A&E doctors/paramedic carers (3) I am concerned that other patients presenting with bleeds from fistula/graft sites might not be escalated for renal/surgical review before a fatal bleed presents. 2 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisations have the power to take such action as you are responsible for setting the health education requirements for medical professionals and/or disseminating best practice for Renal patients. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23rd September 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:- 1. Browne Jacobson LLP 2. Kennedys Law 3. Wilson Browne 4. Radcliffes Le Brasseur 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 28th July 2017 Signed - Hassan Shah 3
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.
Association of Ambulance Chief Executives
3rd floor
32 Southwark Bridge Road
London
SE1 9EU
T: 020 7783 2039
E: info@aace.org.uk
W: www.aace.org.uk
12th September 2017
BY EMAIL: coroners@northantscoroner.com
Hassan Shah
Assistant Coroner for Northamptonshire
Dear Mr Shah
REGULATION 28 REPORT – ACTION TO PREVENT FUTURE DEATHS: PAMELA KEECH
I am writing further to your Regulation 28 report to prevent future deaths which you issued to JRCALC
following the inquest into the death of Pamela Keech.
You requested that the JRCALC consider matters of concern and suggested that action is taken to
prevent future deaths. As detailed in a separate letter to you from JRCALC, it is the AACE and its
advisors NASMeD that are providing the response to you.
Your matters of concern were:
(1) I heard evidence that there is no National Guidance on how to predict and manage a fatal
graft/fistula haemorrhage
(2) I heard evidence that the risk of developing a fatal haemorrhage from a fistula/graft site is not part of
the training requirement for A&E doctors/paramedic carers
(3) I am concerned that other patients presenting with bleeds from fistula/graft sites might not be
escalated for renal/surgical review before a fatal bleed presents. points 1 and 4 which are:
You suggest that action should be taken to prevent future deaths.
The action that we will be taking is to request that JRCALC, acting as our expert clinical advisors,
review the UK ambulance service clinical practice guidelines for the management of renal patients and
specifically in relation to fistula bleeds. We will ensure that any recommendations for new or updated
guidance is written, published and issued to our ambulance clinicians as part of our ongoing clinical
practice guideline development plan.
In addition, have written to the Vascular Access Society of Britain & Ireland to seek specialist advice in
relation to fistula bleeds and whether patients should always be conveyed to hospital, particularly when
bleeding has stopped. There may be opportunities to develop pathways for our clinicians to have direct
clinical discussions with a vascular specialist regarding the most appropriate pre-hospital management
of a patient and to agree whether conveying the patient to hospital is required.
Chairman: Dr Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI
Managing Director: Martin Flaherty OBE
I hope that you will agree that we have responded to the concerns that you have raised and explained
our reasoning. I can assure you that we are absolutely committed to learning from all such adverse
events and doing everything within our power to prevent them happening again in the future.
Yours sincerely
NASMeD Chairman
AACE Managing Director
Chairman: Dr Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc MA FASI
Managing Director: Martin Flaherty OBE
12th September 2017 BY EMAIL: coroners@northantscoroner.com Hassan Shah Assistant Coroner for Northamptonshire Dear Mr Shah REGULATION 28 REPORT – ACTION TO PREVENT FUTURE DEATHS: PAMELA KEECH I am writing further to your Regulation 28 report to prevent future deaths which you issued following the inquest into the death of Pamela Keech. You state that your opinion is that action should be taken to prevent future deaths and believe that the JRCALC organisation has the power to take such action. I wish to inform you that JRCALC are not responsible for setting the health education requirements for paramedics and therefore the full response to this PFD will be sent separately to you from the Association of Ambulance Chief Executives (AACE) and its clinical advisors the National Ambulance Service Medical Directors (NASMeD). JRCALC is a group of specialty experts and its role is to provide robust clinical specialty advice on the instruction of the AACE and its advisors NASMeD. AACE is a formally constituted private company wholly owned by the English Ambulance NHS Trusts who are all full voting members. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Its primary focus is the ongoing development of the English ambulance services and the improvement of patient care. It is a company owned by NHS organisations and it wholly owns the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines. The responsibility for standards of clinical care within Ambulance Trusts rests with the Chief Executives and Medical Directors of each ambulance service. On behalf of AACE, NASMeD provide appropriate assurance and lead the development of future versions of the clinical guidelines. I hope this clarifies JRCALC’s support role to AACE and NASMeD. Please let me know if I am able to provide any further information. Yours sincerely JRCALC Chairman
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