Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0212, written 27 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Jun 2018 |
|---|---|
| Reference | 2018-0212 |
| Deceased | Angela West |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
Coroner ME Hassell HM Senior Coroner Inner North London REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Simon Harrod Clinical Director Bart’s Health NHS Trust Ground Floor, Pathology and Pharmacy Building, The Royal London Hospital, 80 Newark Street, London, £1 2ES CORONER 1am Sarah Bourke, assistant coroner, for the coroner area of Inner North London 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. INVEST! IGATION and INQUEST On 18 July 2017 | commenced an investigation into the death of Angela Sandra lvina West (age 57). The investigation concluded at the end of the inquest on 12 June 2018. The conclusion of the inquest was a narrative conclusion which is set out in the section below. The medical cause of Ms West's death was 1a: acute cardiac arrhythmia 1b: hyperkalaemia and hypovolemia 1c: end stage kidney disease 1d: lithium therapy for bipolar’ disorder 2: cholecystectomy CIRCUMSTANCES OF THE DEATH Angela West had end stage kidney disease, which required dialysis. She underwent surgery to remove her gall bladder at the Royal London Hospital on 6 July 2017. She initially recovered as expected. During 7 July, she became drowsy and had a slightl increased heart rate of 105 bpm. During 8 July, her heart rate increased over the course of the day. She also had increased inflammatory markers and reduced oxygen saturations. Her NEWS score increased from 2 to 5 over the course of the day. The possibility of a bile leak was raised and following a CT scan on the evening of 8 July, a decision was made to undertake a laparoscopy the following day. Once the possibility of a bile leak was identified, other potential reasons for her deterioration were not explored. It was decided that Ms West would have dialysis prior to undergoing laparoscopy because her potassium level was raised at 6.2. Ms West was not referred to the Critical Care Outreach Team until the morning of 9 July. In addition, she was not escalated to Consultants until the afternoon of 9 July. She remained tachycardic. She underwent dialysis during the afternoon. At the end of dialysis, her potassium levels were 4.1, lactates were 5.1 and her heartrate was 140 bpm, which was suggestive of hypovolemia. Ms West returned to her surgical wars around 6 pm. Whilst being assessed by the anaesthetist prior to surgery, she was found to have a respiratory rate of 40 breaths per minute and be tachycardic, confused and peripherally shut down. A venous blood gas showed that she had marked acidosis. Her potassium level was 6.1 and lactate was 10. Ms West went into cardiac arrest whilst being positioned for a chest x-ray. It was not possible to resuscitate her. Her death was confirmed shortly after 8 pm. 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 could 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) Ms West was identified as being at increased risk of surgical complication given her underlying kidney disease. Ms West's surgery was listed for a Thursday. The effect of this was that much of her care in the period following her deterioration was dealt with under weekend staffing arrangements. (2) Ms West was located on a general surgical ward. (3) The investigation highlighted issues relating to Ms West becoming dehydrated. Neither myself nor the clinical investigators were able to locate any fluid balance charts for Ms West. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 23 August 2018. |, 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 I have sent a copy of my report to the Chief Coroner and to the following interested Persons. : e | OS West's daughter) 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. . Sarah Bourke Assistant Coroner 27 June 2018
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.
24 August 2018 PRIVATE & CONFIDENTIAL Sarah Bourke Assistant Coroner Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES Telephone: 020 32460641 Chief Medical Officer Alistair Chesser www.bartshealth.nhs.uk Dear Ms Bourke Thank you for your correspondence regarding a prevention of future deaths notice following the inquest on Angela West. You describe three areas of concern: Ms West was identified as being at increased risk of surgical complication given her underlying renal disease. Ms West’s surgery was listed for a Thursday. The effect of this was that much of her care in the period following her deterioration was dealt with under weekend staffing arrangements. Appropriate plans were made on the basis that Ms West had renal disease and needed regular dialysis. The procedure was planned with the renal team and Ms West was dialysed as per normal on the Wednesday and again on Friday. The surgery was moved around to accommodate this. The Royal London Hospital is fully operational over seven days and 24 hours; high risk surgery can be performed at any time including weekends. Elective high risk surgery has to be performed every day during the working week and weekend staff are fully prepared and set up for post-operative care of high risk surgeries. We recognise that these high standards need to be maintained for all patients and on all our acute surgery wards. The following has also been implemented to strengthen this aspect: The out of hour’s surgical cover has been enhanced to ensure daily review of acute inpatients seven days a week The junior doctor’s induction programme now contains a section around clinical escalation. The numbers of overall doctors in the surgery department have increased and there is a good mixture of skills sets throughout shifts. This specific case has also been presented three times at various fora including the surgical Mortality and Morbidity meeting. This has ensured that a large number of clinical staff have learned from this case. A safety event has taken place which also focused on the lessons to be learned from this case. Enhanced training on the management of the deteriorating patient is continuing to be provided to all clinical staff Ms West was located on a general surgical ward. All our surgical wards expect to look after high risk patients and it’s not unusual to have renal patients such as Ms West on our wards as we have a large cohort of renal patients at the RLH as we are a large renal unit. The doctors and nurses on the ward are highly skilled at dealing with a range of general and complex complications. The renal team, being on site, are easily available when required, and review all inpatients daily seven days a week if needed, irrespective of the ward on which the patient lies. We recognise the risks for patients when the skills and attentions of two or more specialties are involved. Each of the teams involved has discussed their role in ensuring strong teamwork. The investigation highlighted issues relating to Ms West becoming dehydrated. Neither I nor the clinical investigators were able to locate any fluid balance charts for Ms West. Our legal team have in fact found a fluid chart started in the early hours of the day that she died. However after the initial operation it was expected that Ms West would go home so we would not expect a fluid chart for this earlier period. On the renal unit a fluid balance would be kept during dialysis Although Ms West was known to be a patient who did not make urine (due to her kidney disease) we would expect that when she deteriorated a fluid chart would be started to measure other fluid losses and fluid intake. This indeed was started, but could not be found during the original investigation. The measurement and management of fluid balance is part of the learning for this clinical team and for the wider organisation from this incident. I am very happy to discuss or clarify any of the above points Yours sincerely Alistair Chesser Chief Medical Officer Barts Health NHS Trust CC: Simon Harrod, Medical Director, Royal London Hospital
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