Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0457, written 25 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 | 25 Aug 2017 |
|---|---|
| Reference | 2017-0457 |
| Deceased | Sam Crick |
| Coroner | David Heming |
| Coroner area | Cambridgeshire and Peterborough |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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.
David Heming Senior Coroner for Cambridgeshire and Peterborough REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Matthew Hopkins, Chief Executive, Barking, Havering and Redbridge University Hospitals NHS Trust 2. Care Quality Commission 3. Simon Stevens, Chief Executive Officer, NHS England 1 [SORONER | am David Heming, Senior Coroner for Cambridgeshire and Peterborough 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. http:/Awww.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http:/Avww. legislation.gov.uk/uksi/2013/1629/part/7/made 3. | INVESTIGATION and INQUEST On the 8'" March 2016 | commenced an investigation into the death of Sam Antony Crick, aged 24 years. The investigation concluded at the end of the inquest on the 5" April 2017. The medical cause of death was:- 1a. Obstructive hydrocephalus. 1b. Midbrain glioma There was a narrative conclusion that he - died from complications of raised intracranial pressure resulting from the late failure of an endoscopic third ventriculostomy. Neurosurgical intervention on or prior to the 28th February 2016 would have led to survival. 4 | CIRCUMSTANCES OF THE DEATH The deceased underwent an endoscopic third ventriculostomy on the 26th October 2007 that was performed >I Consuttant Neurosurgeon. A scan had also revealed subtle abnormalities in the tectum which was subsequently reported radiologically as a tectal plate tumour. The deceased was subject to periodic ophthalmology reviews, which were relayed to the neurosurgical department at Queens where he was still being monitored until he was discharged from further surveillance there on the 20th Coroner's Office, Lawrence Court, Princes Street, Huntingdon, Cambridgeshire, PE29 3PA Tel 0345 045 1364 | Fax 01480 372777 November 2012. In the summer of 2015, he became symptomatic again and an MRI scan was subsequently obtained on the 31st October 2015 at the Luton and Dunstable (L and D) hospital as he had been referred there by his GP. Consultant Neurologist saw him in clinic on the 4th November 2015 and there was a referral letter sent the same day to the Queens Hospital Romford requesting an urgent assessment. It was stated that the October 2015 MRI scan revealed hydrocephalus. In addition, a more comprehensive letter from IEEE was sent that set out the investigation undertaken and the scan findings and detailed the symptoms from the summer of 2015 onwards. There was noted to be a constant dull headache which had been present from the middle of September 2015 with episodes of dizziness and the fundoscopic examination Ec recorded as finding bilateral papilledema. In addition to referral to Queens Hospital, Romford, there was mention of an urgent ophthalmological examination and this was conducted by Consultant Ophthalmologist at L and D at a clinic appointment on the 18th November 2015 where funda! examination revealed papilledema, which is a sign of raised pressure in the head consistent with his MRI scan result of hydrocephalus. HR «viewed again on the 24'" December 2015. The right optic disc was slightly more swollen, visual acuity was normal and visual fields were generally depressed. On the 20th November 2015, two clinicians at the Queens Hospital namely fi as Cee el (Consultant Neurosurgeon and Consultant Neuro-Interventional Radiologist met and discussed the October 2015 MRI scan from the L and D .!t was recorded that there was no change in the tumour or hydrocephalus on the October 2015 scan when comparing with an earlier 2010 scan. a «a Sam in a clinic appointment on the 2nd December 2015. He recorded symptoms of headaches, dizziness and some blurring of vision and on examination noted there was no frank papilledema but the margins of his discs were probably a bit blurred On the 4th December he discussed the scans in a neuroradiology MDT where a Consultant Neuroradiologist felt there had been a slight increase in the mid brain lesion and it was also felt that there had been some increase in the ventricular size in comparison to the 2012 MRI scan and CISS sequence MRI scans were requested. An MRI scan was undertaken at the Queens hospital on the 26th January 2016. The scan was reviewed En on the 3rd February 2016 when he saw the deceased in clinic — although the early part of the consultation had been conducted b a neurosurgery registrar. The decision Coroner's Office, Lawrence Court, Princes Street, Huntingdon, Cambridgeshire, PE29 3PA Tel 0345 045 1364 | Fax 01480372777 was to refer to Mr. John Brecknell for review. A neuroradiology report of EE was produced on the 4th February 2016, the day after the clinic appointment HR viewed the scans on the 22nd February 2016 and an outpatient appointment was requested on a soon as basis and this was arranged for May 2016. The deceased suffered a catastrophic collapse on the 29th February 2016 and following assessment he was transferred to Addenbrookes hospital but despite a neurosurgical intervention that evening, the brain damaging incident was irreversible and he died on the 4th March 2016. At post mortem examination i! Consultant neuropathologist found evidence of chronically raised intracranial pressure with the cerebral swelling having remodeled the inner surface of the skull over time. | found as a fact that the symptoms the deceased suffered from the latter part of 2015 onwards arose from a recurrence of his hydrocephalus with consequent and progressive increase in intracranial pressure that ultimately resulted in the catastrophic collapse on the 29th February 2016 which marked the tipping point of his tolerance threshold. The cause was on balance a late failure of the endoscopic third ventriculostomy which was no longer functioning as an effective diversion of cerebrospinal fluid and was leading to raised intracranial pressure. Box 3 of the record of inquest was completed as follows :- On the 4th March 2016 at Addenbrookes Hospital Hills Road Cambridge from severe and diffuse hypoxic brain damage resulting from raised intracranial pressure (operated on with an external ventricular drain insertion as an emergency transfer patient on the 29th February 2016) with central herniation and downward displacement of the brain stem that had led to a Duret haemorrhage. Earlier Neurosurgical management at another hospital from early December 2015 onwards was in an outpatient list framework on a semi urgent basis and no operation was planned prior to his collapse on the 29th February 2016, but the clinical and radiological picture was of progressive rising intracranial pressure as evidenced by herniation of brain parenchyma through a burr hole, papilledema and other symptoms which would have been relieved by prompt inpatient surgery 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. Coroner's Office, Lawrence Court, Princes Street, Huntingdon, Cambridgeshire, PE29 3PA Tel 0345 045 1364 | Fax 01480 372777 The MATTERS OF CONCERN are as follows. — To BHRT (A).This was a significant adverse event and the death was preventable. However, there has been no serious incident report (SIR) into the death. The importance of the SIR process is to consider root causes and importantly, to make recommendations and implement an action plan. Learning lessons is a key feature of the process. (B). The neuroradiological review of the CT scan in November 2015 and early December 2015 did not highlight the obvious brain parenchymal herniation through the pre-existing burr hole as well as other interval change and this was a missed opportunity of flagging a clear indicator of rising intracranial pressure. Furthermore, there is now a separate investigation on the death of another person (SP) where involvement of the neuroradiology department at the Queens hospital is a central issue. (C). The last face to face consultation between the Neurosurgeon and the deceased was on the 3rd February 2016 but the written neuroradiological report of the January 26th CT scan was not available until the 4th February 2016 and so this report was not considered by the Neurosurgeon as it was not available for this key consultation. This report did highlight some alarming features of herniation but this vital information was therefore not considered. (D). The consultant neurosurgeons examination on the 2 December 2015 did not find frank papilledema and yet an examination by a consultant ophthalmologist at the Luton and Dunstable hospital on the 18° November 2015 and 24" December 2015 had found papilledema at both appointments. The consultant neurologist’s referral letter from Luton and Dunstable indicated a finding of papilledema also and stated an ophthalmic review was being sought but there appears to have been no attempt to find the outcome of the Luton assessments. Further, and in the alternative, no specialist ophthalmic advice was sought by the neurosurgeon even though there had been lengthy ophthalmic follow up over a number of years after the third ventriculostomy in 2007 and also given the recorded findings of the consultant neurologist in Luton. To BHRT and the CQC (E). There have been a number of Regulation 28 reports issued by Nadia Persaud, Senior Coroner for the area of the Eastern Area of Greater London raising concerns over a number of clinical deaths. In addition, a CQC inspection in September 2016 and October 2016 (report published March 2017) have made findings of the trust ‘requiring improvement’ in a number of respects when measuring against key standards. The CQC report published in December 2013 referred to a previous mortality alert concerning septicaemia shunting in hydrocephalus where the hospital review found no obvious deficits in clinical or operative quality. This inquest was an independent review where expert evidence exposed shortcomings in the management of hydrocephalus. It is not clear whether the circumstances of this death were disclosed during the most recent inspection Coroner's Office, Lawrence Court, Princes Street, Huntingdon, Cambridgeshire, PE29 3PA. Tel 0345 045 1364 | Fax 01480 372777 NHS ENGLAND (F). A point explored in the investigation was the administration of opioid analgesia in someone who has raised intracranial pressure. This was looking at an opiate acting as a respiratory depressant with a consequent rise in the level of carbon dioxide in the blood which in turn could further raise ICP provoked by hypercapnia. This could cause a fatality. Luton and Dunstable hospital have designed a standard operating procedure to address this and it raises a question of whether this should be distributed nationally so as to achieve consistency of approach. 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 the 20th October 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 :- BS 0th) (Father). Luton and Dunstable university Hospital NHS Foundation Trust. | 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. Dated 25" August 2017 \ TN - Signature _! David Heming, Senior Coroner for Cambridgeshire and Peterborough Coroner's Office, Lawrence Court, Princes Street, Huntingdon, Cambridgeshire, PE29 3PA Tel 0345 045 1364 | Fax 01480 372777
3 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.
Barking, Havering and Redbridge NHS| University Hospitals NHS Trust PRIVATE & CONFIDENTIAL Executive Offices Mr Heming First floor, Neutral zone Her Majesty’s Coroner Queen's Hospital Lawrence Court Rom Valley Way, Romford, Essex RM7 OAG Princess Street Huntingdon Tel: 01708 435 000 PE29 3PA www .bhrhospitals.nhs.uk W @BHR_hospitals Date: 18 October 2017 Dear Mr Heming Sam Antony Crick, Deceased | am writing in response to your Regulation 28 report dated 25 August 2017, following the inquest hearing into the sad death of Mr Sam Antony Crick. In your Regulation 28 report you sought reassurance in relation to issues surrounding the neurosurgical management of Sam Crick at Queens’ Hospital (the ‘Trust’); 5 areas of concern were highlighted which | address in turn, below. A. Lack of a Serious Incident Report (SIR) into the death. Trust Response An SIR was not initially triggered in this case as the Trust was not notified of Sam Crick’s death. The Trust only became aware of Sam’s death when , Consultant Neurosurgeon wrote to the family to investigate why the patient had not attended a clinic appointment with in May 2016. It is normal practice for the Division to discuss all deaths at the Trust within 30 days of death and where indicated to notify of a potential SI in accordance with the Trust’s Incident & Serious Incident Policy. At the time of Sam’s death the Trust had no process to review externally reported deaths. This will be addressed in the SIR with a recommendation that all externally reported deaths are reviewed weekly as part of a Morbidity and Mortality session to identify any lessons and feedback to referring hospitals. Following receipt of the Coroner’s Regulation 28 report a Significant Incident (Sl!) notification was completed by the Division and an Sl declared by the Trust’s corporate team on 31 August 2017. SI investigations are currently ongoing and the report will be shared with the Clinical Commissioning Groups (CCG’s); Barking, Havering and Redbridge Clinical Commissioning Group (BHRCCG) and North East London Commissioning Support Group (NELCSU) on or before 23 November 2017. The CCG’s then has 20 days to consider the report and agree the findings. UCLPartners IGMOKEERES ARIHP Acting Chair: Chief Executive: Matthew Hopkins Once the report has been agreed by the CCG’s the report will be shared with the family. The Trust will implement an action plan in the timescale agreed in the SIR, based on the lessons learned from this case. The neuro-radiological review of the CT scan in November 2015 and early December 2015 did not highlight the obvious brain parenchymal herniation through the re-existing burr hole as well as other interval change and this was a missed opportunity of flagging a clear indicator of rising intracranial pressure. Trust Response The neuro-radiological review of the CT scans in November 2015 and early December 2015 did not highlight the brain parenchymal herniation through the re-existing burr hole as this finding was missed. This is a an exceptionally rare complication; the Neuro-radiologist who reported the scan and who has 17 years of experience as a Consultant Neuro-radiologist has never previously encountered this complication. The Trust acknowledge this finding was missed by the reporting Neuro-radiologist but does not accept that the finding was ‘obvious’ as suggested. The worsening hydrocephalus and raised intra cranial pressure were both documented on the 26 January 2016 imaging and reported on 4 February 2016. The further subtle finding of the herniation, were not noted. The ongoing SIR investigation will include recommendations on improved management of patients with known, high, raised intercranial pressure including clear guidelines on how to escalate concerns and the development of a Rapid Review Access Clinic'to enable appropriate triage of patients. The last face to face consultation between the neurosurgeon and Sam was on 03.02.16 but the written neuro-radiological report of the 26 January 2016 CT scan was not available until 4 February 2016 so this report was not considered by the neurosurgeon as it was not available for this key consultation. This report did highlight some alarming features of herniation but this vital information was therefore not considered (prior to Sam’s appointment on 3 February 2016) Trust Response Responsibility for following up imaging requests rests with the requester and the Trust accepts that in Sam’s case, the imaging was not available for his clinic appointment on 3 February 2017 as it should have been. In reviewing radiology processes the Trust has identified the need to improve the quality of radiology requests. On 17 August the Medical Director cascaded to all clinical staff a set of standards expected of clinicians in making a radiology request. A copy of the email dated 17 August 2017 is attached for your information, . The neurosurgeons examination on 02.12.15 did not find frank papilledema yet an examination by a consultant ophthalmologist at the Luton and Dunstable hospital on 18 November 2015 and 24 December 2015 had found papilledema at both appointments. The consultant neurologist’s referral letter from Luton and Dunstable indicated a finding of papilloedema also and stated an ophthalmic review was being sought but there appears to have been no attempt to find out the outcome of the Luton’s assessments. Further, and in the alternative, no specialist ophthalmic advice was sought by the neurosurgeon even though there had been lengthy ophthalmic follow up over a number of years after the third ventriculostomy in 2007 and also given the recorded findings of the consultant neurologist in Luton. Trust Response The Consultant Neurosurgeon involved in these examinations is no. longer practicing in the Trust and is therefore unable to personally comment. These failures are however, being investigated as part of the ongoing SIR and recommendations will be made to ensure that these issues do not happen again. To BHRUT and the CQC E. There have been a number of Regulation 28 reports issued by Nadia Persaud, Senior Coroner for the area of Eastern Area of Greater London raising concerns over a number of clinical deaths. In addition , a CQC inspection in September 2016 and October 2016 (report published in March 2017) have made findings of the Trust ‘requiring improvement’ in a number of respects when measured against key standards. The CQC report published in 2013 referred to a previous mortality alert concerning septicaemia shunting in hydrocephalus where the hospital review found no obvious deficits in clinical or Operative quality. This inquest was an independent review where expert evidence exposed shortcomings in the management of hydrocephalus. It is not clear whether the circumstances of this death were disclosed during the most recent inspection. Trust Response The circumstances of this patient’s death were not disclosed during the most recent inspection by the CQC as this information was unknown at the time; routine disclosure of individual patient deaths is not a cac requirement. Since April 2017 all Trusts have been required to collate and publish quarterly information on deaths in accordance with National Guidance on Learning from Deaths. The Trust has developed a ‘Learning from Deaths’ policy in accordance with the national guidance which sets out how the Trust responds to and learns from, deaths of patients who die under its management. The Trust is committed to continuing to learn from Inquests. Please let me know if you require further information. Yours sincerely Dr Nadeem Moghal Executive Medical Director
CareQuality - Commission aero Commission Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161 www.cqc.org.uk Mr Heming H.M. Senior Coroner for Cambridgeshire and Peterborough Lawrence Court Princess Street Huntingdon PE29 3PA 8 December 2017 Private and Confidential By Email: coroners@cambridgeshire.gov.uk Care Quality Commission Our Reference: MRR1-4422151912 Prevention of future death report following inquest into the death of Mr Sam Crick. Dear Mr Heming Thank you for sending CQC a copy of the prevention of future death report issued following the death of Mr Sam Crick. CQC has contacted the provider Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) to request written confirmation and evidence of the action they have taken to date following this death and any additional action they intend to take in response to the prevention of future death report. BHRUT are due to conclude their serious incident investigation into the death of Mr Crick this week and will share their findings with CQC accordingly. We note the legal requirement upon BHRUT to respond to your report within 56 days. In your report you have additionally asked CQC to provide further clarity on a few points that | have dealt with individually below: Increase in number of Regulation reports raising concerns over number of deaths at BHRUT The CQC, in communication with the trust and relevant stakeholders, have recognised the increase in frequency of Regulation 28 reports relating to BHRUT. With a view to addressing this at a trust-wide level, the CCG has implemented an enhanced programme of review with the trust. The CCG have been provided with a quality risk profiling tool by NHS England which includes self-assessment by the trust and assessment from their regulatory stakeholders (CCG, CQC, NHSE), which is based on the Key Lines of Enquiry (KLOEs) of the CQC. This is a means for the trust to evaluate and score their performance in relation to risk management in key areas, while a similar score is completed by stakeholders. The scores gathered from this process are then discussed in a mediated meeting. Where there are discrepancies between self-assessment and assessment from stakeholders, action plans for improvement are put in place. Members of the trust senior leadership team attended the first meeting in November where CQC were present. There was not enough time to discuss all the matters of concern and a follow up meeting, which will include a focus on Regulation 28 reports, is to be planned for early January. Recent inspection of BHRUT and related findings: In 2016, we carried out a focused inspection of a number of core services that had previously been rated as requires improvement. The neurosurgery provision would fall under the core service of surgery, which was not included in our most recent inspection of the trust, as our intelligence monitoring did not lead us to have specific concern about surgery services at this time. However, this is an agreed priority for future inspections. The radiology provision was covered under the outpatients department, where the main concern was around medical staffing vacancies in the radiology department. Recent stakeholder engagement (particularly with the CCG) has raised concern in relation to risk management and governance. The Trust recently returned their Provider Information Return (PIR), a location level assessment that provides essential data and information to support the ongoing monitoring of quality of care and to plan and inform inspections. Along with other sources of intelligence, we considered the PIR at a regulatory planning meeting (RPM) in early December where proposals for inspection were discussed and agreed. The previous mortality alert concerning septicaemia shunting in hydrocephalus where the hospital review found no deficits in clinical or operative quality that was referred to in the 2013 CQC inspection report of BHRUT: The CQC outliers team reviewed the information the Trust provided at the time. It was noted that a case note review had been undertaken for the 13 patients identified in thei analysis and that the reviewers concluded that in none of the cases of external ventricular drainage was there any evidence that drain placement was a factor in the patients’ death. Subsequently, additional enquires were not undertaken. Future regulatory action: Following the recent RPM, we are planning to inspect specific core services at BHRUT in the first part of 2018. As part of our next phase inspection methodology, this will include specific consideration to how well-led the trust is; hence, we are scheduling a further 3 day in-depth inspection of the leadership and governance of the trust. Please do let me know if you require any further information in relation to any of the above. We will be happy to update you in due course. Yours sincerely Wd CQC Head of Hospital Inspection, London
INHS England Professor Sir Bruce Keogh National Medical Director Skipton House 80 London Road Mr David Heming SE1 6LH Coroner's Office, Lawrence Court, Princess Street, Huntingdon, Cambridgeshire, PE29 3PA tA 4 Zy November 2017 Dear Mr Heming, Re: Regulation 28 Report to Prevent Future Deaths — Sam Crick (died 04.03.2076) Thank you for your Regulation 28 Report dated 2 August 2017concerning the death of Mr Crick on 4" March 2016. Firstly, | would like to express my deep condolences to Mr Crick's family. The regulation 28 report concludes Mr Crick’s death was a result of complications of raised intracranial pressure resulting from the late failure of an endoscopic third ventriculostomy. It was also concluded that a timely neurological intervention would have saved his life. Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding the administration of opiates in someone with raised intracranial pressure and/ or an altered level of consciousness. Specifically, you are concemed that the opiate could act as a respiratory depressant leading to raised levels of carbon dioxide in the blood which could ultimately be fatal and, therefore, constitutes a risk of future deaths. As a result, NHS England has given careful consideration to your recommendation and has sought professional advice from the Society of British Neurological Surgeons (SBNS). They have discussed this case in greater detail at their Council meeting and agreed that it would be beneficial to increase awareness among professionals on the use of opiate medication in patients with intracranial pressure. Consequently, the SBNS have recommended the most effective solution to address these concerns would be for the NHS to issue a guidance statement jointly with the Royal College of Emergency Medicine. This will focus on treating patients with raised intracranial pressure and urge extreme caution in relation to the use of opiates. NHS England will work with these professional bodies to help produce and distribute this statement nationally within the next 6 months. High quality care for all, now and for future generations We are pleased to tearn Luton and Dunstable hospital have since developed a local standard operating procedure (SOP) for such cases. However, further work would be needed to validate their guidance to determine if this guidance should be adopted nationally. We believe that rather than sharing this SOP, the above suggested guidance will have a greater impact across the NHS by effectively reaching the right professions with a national statement. NHS England acknowledges the concerns you have raised with the Trust and we will seek their assurances that they have addressed such matters in line with the Serious Incident Framework. We will also suggest to the Trust that an independent review of the case management ought to be carried out as this would be helpful in understanding the failings in this case and to prevent any future deaths. 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 High quality care for all, now and for future generations
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