Prevention of Future Deaths reports · 2018

Rita Taylor

Regulation 28 report to prevent future deaths, reference 2018-0225, written 12 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report12 Jun 2018
Reference2018-0225
DeceasedRita Taylor
CoronerKaren Henderson
Coroner areaSurrey
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedEpsom and St Helier University Hospitals NHS Trust
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

IN THE SURREY CORONER’S COURT 
IN THE MATTER OF: 

__________________________________________________________ 

The Inquest Touching the Death of Rita Taylor  
A Regulation 28 Report – Action to Prevent Future Deaths 
__________________________________________________________ 

THIS REPORT IS BEING SENT TO: 

1.  Chief Executive, Epsom General Hospital 
2.  Royal College of Physicians 
3.  Care Quality Commission 

1  CORONER 

Dr Karen Henderson, HM Assistant Coroner for Surrey 

2  CORONER’S LEGAL POWERS 

I make this report under paragraph 7(1) of Schedule 5 to The Coroners 
and Justice Act 2009. 

3 

INVESTIGATION and INQUEST 

On 23rd May 2018 I commenced and concluded an investigation into the 
death of Rita Taylor, 80 years of age. The medical cause of death given 
was: 

1a. Pneumonia 
1b. Central Pontine Myelinolysis 
1c 

2.  - 

My narrative conclusion was:  

Mrs Taylor died as a result of sub-optimal care contributed to by 
neglect 

4  CIRCUMSTANCES OF THE DEATH 

RT4563 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Mrs Taylor, 80 years old, was admitted into Epsom General Hospital 
on 31st July 2017 following a collapse with confusion at the Meadows 
Hospital. She had been admitted there on 7th July 2017 for treatment of 
psychosis thought to be secondary to hydrocortisone therapy for a 
pituitary adenoma, which was under review by the endocrinology 
department at St George’s hospital.  

Mrs Taylor had been previously admitted to Kingston Hospital on the 
4th June 2017 with signs of confusion and paranoia. At that time, this 
was thought to be related to a urinary tract infection which was treated. 
She was also noted to be hyponatraemic which was corrected. At the 
same time, she was diagnosed with diabetes insipidus and prescribed 
desmopressin in addition to her hydrocortisone for her pituitary 
adenoma. 

On admission to Epsom hospital A&E department Mrs Taylor was 
found to have a GCS 14/15 with some confusion. She was 
haemodynamically stable. Investigations revealed a serum sodium of 
111 mmol/l. She was given 1 L normal saline and desmopressin was 
withheld as it was known to cause hyponatraemia. She was admitted 
under the care of the on call medical physician. 

Mrs Taylor was seen by the on call consultant physician at or around 6 
pm on the 31st July 2017. No treatment was instituted to monitor or 
treat the hyponatraemia. There was no documentation from the 
consultant with regard to that consultation. 

On the 1st August, Mrs Taylor was reviewed by a consultant emergency 
care physician with a specialist interest in endocrinology. Mrs Taylor’s 
serum sodium was noted to have increased to 129 mmol/l by 11.00 am 
but there is no evidence that the rapid rate of increase was understood 
to be beyond the recommended national guidelines and no steps were 
put in place to regularly assess serum sodium levels as recommended 
by national guidelines.  

The management plan was to continue to withhold desmopressin, to 
provide potassium replacement through intravenous fluids and to 
contact St George’s hospital for advice. This was attempted but it was 
not successful. 

Mrs Taylor was incontinent. Urinary catheterisation was considered 
but not undertaken preventing any fluid balance assessment which, in 
any event, was not requested despite a diagnosis of diabetes insipidus.  

RT4563 

2 

 
 
 
 
 
 
 Mrs Taylor was not reviewed following the consultant ward round. 
Documentation was minimal and no plan was made with regard to 
ongoing supervision and treatment. 

On the 2nd August Mrs Taylor was reviewed by another consultant 
emergency care consultant physician with a specialist interest in 
endocrinology. Mrs Taylor was sitting out of bed, alert and eating 
breakfast. Her serum sodium was within normal limits, but no plans 
were put in place to assess serum sodium as recommended by national 
guidelines. There was no consideration of resuming desmopressin and 
no consideration was made or documented to manage the 
consequences of untreated diabetes insipidus. Potassium replacement 
therapy was initiated with intravenous normal saline and 40 mmol/l of 
potassium chloride despite being able to eat and drink at that point.  St 
George’s hospital was not contacted. Documentation was minimal. 

On the 3rd August Mrs Taylor was reviewed by another consultant 
emergency care physician who felt that she was ready for discharge 
planning.  Mrs Taylor’s sodium level had increased to 146 mmol/l 
having increased from 134 mmol/l the previous day. No thought was 
given to this rise and no plans were considered or implemented to 
assess serum sodium as recommended by national guidelines. There 
was no consideration of resuming desmopressin or to assess fluid 
balance and no plan was put in place to manage the consequences of 
untreated diabetes insipidus. St George’s hospital was not contacted. 
Documentation was minimal. 

On the 4th August, Mrs Taylor was transferred to the care of the elderly 
medical ward under the care of a geriatrician although it had been 
proposed for her to be transferred to a specialist endocrine ward. She 
was reviewed by a Specialist Registrar who noted Mrs Taylor was very 
drowsy. She vomited and was thought to have aspirated. Her serum 
sodium was found to be 164 mmol/l. After consultation with the 
consultant geriatrician and the consultant who reviewed her on the 2nd 
August, intravenous normal saline was replaced by dextrose saline. It is 
unclear what further management was instituted although 
desmopressin recommenced on 5th August. 

It is unclear how Mrs Taylor was managed until the evening of the 6th 
August when the intensive care specialist registrar was contacted 
because of concerns of increasing oxygen requirement. Mrs Taylor was 
assessed and found to be in a minimally conscious state. Her serum 

RT4563 

3 

 
 
 
 
 
 sodium level was elevated at 152 mmol/l. The Intensive care consultant 
considered the acute deterioration of Mrs Taylor was a consequence of 
rapid changes in serum sodium secondary to omission of desmopressin 
and untreated diabetes insipidus.  

Mrs Taylor was transferred to the high dependency unit. Radiological 
examination confirmed the diagnosis of central pontine myelinolysis. 
Despite optimal treatment from that point, Mrs Taylor showed no signs 
of recovery and she died on the 15th August 2017.  

It was accepted in Court that Mrs Taylor died as a direct consequence 
of the failure, from admission until the 6th August 2017 to appropriately 
assess and manage hyponatraemia and diabetes insipidus, arising from 
a pituitary adenoma. 

5  CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving 
rise for concern. In my opinion there is a risk that future death 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.  The failure to appropriately manage Mrs Taylor’s hyponatraemia 
by  the  on  call  consultant  physician  on  the  31st  July  2017  on  the 
grounds that it was not his sphere of expertise. No contact was 
considered or made to someone who may have been able to assist 
leaving  Mrs  Taylor  to languish  overnight  with  no  management 
plan in place and a lack of any meaningful documentation in her 
hospital notes.  

2.  The failure, at any time between the 31st July 2017 and 5th August 
2017  to  follow  the  national  recommended  guidelines  for  the 
management  and  treatment  of  hyponatraemia,  in  particular  the 
need to measure serum sodium regularly and to limit the rate of 
rise of serum sodium to prevent complications. 

3.  The  failure,  at  any  time  between  the  31st  July  2017  until  the  6th 
August 2017 to create a coherent plan for the management of Mrs 
Taylors medical problems resulting in the failure to assess fluid 
balance or to reintroduce desmopressin, given a known diagnosis 
of diabetes insipidus on a background of a pituitary adenoma. 

RT4563 

4 

 
 
    
 
 
 
 
 
 4.  The  apparent 

the  appropriate 
lack  of  understanding  of 
management  of  hyponatraemia  by  consultants  whose  care  Mrs 
Taylor was under, despite two emergency consultant physicians 
having a specialist interest in endocrinology. Whilst some attempt 
was made to contact St George’s hospital this was not successfully 
followed through to assist them in their management. 

5.  The failure of an emergency consultant physician with an interest 
in  endocrinology  to  understand  that  giving  intravenous  fluids 
with potassium is not an appropriate method to increase serum 
potassium levels, more so as Mrs Taylor at that time could eat and 
drink normally. 

6.  The  documentation  throughout  Mrs  Taylor’s  admission  until 
transfer  to  the  high  dependency  unit  was  inadequate  with  no 
record of assessment or a coherent management plan in place to 
ensure appropriate care and continuity of that care for succeeding 
physicians to consider or to follow. 

7.  As  was  acknowledged  in  Court,  the  SI  report  did  not  fulfil  its 
obligations  and  it  was  agreed  that  it  would  be  extensively  re-
written  and  re-presented  to  HM  Coroner’s  Court  to  more 
accurately reflect the circumstances of Mrs Taylor’s death and the 
learning points required to assist in preventing any future deaths.  

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I 
believe that the people listed in paragraph one above have the power to 
take such action. 

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of its 
date; I may extend that period on request. 

Your response must contain details of action taken or proposed to be 
taken, setting out the timetable for such action. Otherwise you must 
explain why no action is proposed. 

8  COPIES 

I have sent a copy of this report to the following: 

RT4563 

5 

 
 
 
 
 
 
 
 
 
 1.  See names in paragraph 1 above 
2. 
 (husband) 
3. 
4.
5. 
6. 
7. 
8. 
9.  General Medical Council 
10. The Chief Coroner 

In addition to this report, I am 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 at the time of your response, about the release or 
the publication of your response by the Chief Coroner.  

Signed: 

Karen HENDERSON 

DATED this 12th June 2018 

RT4563 

6

Responses

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.

Response from Epsom and St Helier University Hospitals NHS Trust (PDF)
INHS|

Epsom and St Helier

University Hospitals
NHS Trust

Ms Karen Henderson

Assistant Coroner Chief Executive’s Office
HM Coroner's Court for Woking St Helier Hospital
Wrythe Lane

Carshalton

Surrey SM5 1AA

ve:

Web: www.epsom-sthelier.nhs.uk

5 September 2018

Dear Ms Henderson

Rita Taylor (Deceased)
Response to Regulation 28 Report to Prevent Future Deaths

This letter comprises the formal response of Epsom and St Helier University Hospitals
NHS Trust ‘the Trust’ to the issues raised in the Regulation 28 Report to Prevent Future
Deaths, dated 12 July 2018, ‘the Report’, made subsequent fo the inquest into the death of
Rita Taylor.

A copy of this letter will also be shared with the family of Mrs Taylor, to whom the Trust
would like to express our deepest sympathy and condolences.

Background

Mrs Rita Taylor was admitted to Epsom General Hospital on 31 July 2017 from ‘The
Meadows’, a mental health unit, following a collapse. She had a history of hypopituitarism
requiring hormone replacement with desmopressin and steroids. On arrival to the
Emergency Department (ED) she was confused but fully conscious and had normal blood
pressure and breathing. Blood tests revealed profound hyponatraemia and moderate
hypokalaemia. Over the next four days Mrs Taylor's desmopressin was withheld and her
sodium levels rose too quickly and too high and she developed osmotic demyelination
syndrome (central pontine myelinolysis) which resulted in brain damage and death.

The death was reported to the coroner and a post mortem was performed which gave the
medical cause of death as:

ja. Pneumonia

1b. Central Pontine Myelinolysis

Great care to every patient, every day
Patient Advice and Liaison Service (PALS) 020 8296 2508 | Main Switchboard 020 8296 2000

Chalrman Laurence Newman | Ghlef Executive Danie! Elkeles

The following narrative conclusion was delivered at the inquest:
‘Mrs Taylor died as a result of sub-optimal care contributed to by neglect.’

The Report raises the following concerns:

4. The failure to appropriately manage Mrs Taylor's hyponatraemia by the on
call‘consultant physician on the 31st July 2017 on the grounds that it was not
his sphere of expertise. No contact was considered or made to someone who
may have been able to assist leaving Mrs Taylor to languish overnight with
no management plan in place and a lack of any meaningful documentation in
her hospital notes.

2. The failure, at any time between the 31st July and 5th August 2017 to follow
the national recommended guidelines for the management and treatment of
hyponatraemia, in particular the need to measure serum sodium regularly
and to limit the rate of rise of serum sodium to prevent complications.

3. The failure, at any time between the 31st July until the 6th August 2017 to
create a coherent plan for the management of Mrs Taylor's medical problems
resulting in the failure to assess fluid balance or to reintroduce desmopressin,
given a known diagnosis of diabetes insipidus on a background of a pituitary
adenoma.

4. The apparent lack of understanding of the appropriate management of
hyponatraemia by consultants whose care Mrs Taylor was under, despite two
emergency consultant physicians having a specialist interest in
endocrinology. Whilst some attempt was made to contact St George’s
hospital this was not successfully followed through to assist them in their
management.

5. The failure of an emergency consultant physician with an interest in
endocrinology to understand that giving intravenous fluids with potassium is
not an appropriate method to increase serum potassium levels, more so as
Mrs Taylor at that time could eat and drink normally.

6. The documentation throughout Mrs Taylor's admission until transfer to the
high dependency unit was inadequate with no record of assessment or a
coherent management plan in place to ensure appropriate care and
continuity of that care for succeeding physicians to consider or to follow.

7. As was acknowledged in Court, the SI report did not fulfil its obligations and it
was agreed that it would be extensively rewritten and re-presented to HM
Coroner's Court to more accurately reflect the circumstances of Mrs Taylor's
death and the learning points required to assist in preventing any future
deaths.

Great care to every patient, every day
Patient Advice and Liaison Service (PALS) 020 8296 2508 | Main Switchboard 020 8296 2000
Chairman Laurence Newman | Chief Executive Danie! Elkeles

The Trust’s response to the concerns set out in the Report

We summarise your concerns and the actions being taken forward to address them as
follows:

1.

Concerns 1, 2 and 4 — There was an apparent lack of understanding of the
appropriate management of hyponatraemia among the Acute Medical Unit ‘AMU’
consultants who treated Mrs Taylor.

Response - The Trust has moved the handbook of medical emergencies, which
includes guidance on the management of hyponatraemia, to the Trust intranet, which
can be more easily accessed by staff. (See Recommendation 1 of the Action Plan).
This was completed in August 2018.

Recommendation 2 of the Action Plan confirms the guidance on the management of
hyponatraemia will be updated and relaunched. The guidance has been updated
and is currently going through the approval process with the Medicines Management
Committee which is made up of clinical representatives across the hospital. The
Trust's Communication Team will share the updated guidance with all clinical staff
and appropriate education around the updated guidance will be arranged.

Concern 3 — There was a lack of a management plan for the treatment and
monitoring of patients with hyponatraemia.

Response - The AMU lead within the Trust is devising a new pro - forma for the
documentation of monitoring plans for patients. Recommendation 6 of the RCA report
specifies the need for the monitoring plan for patients with hyponatraemia to set out
the desired rate of rise of that patient's sodium and the risks associated with a rise
steeper than this. The monitoring plan will also set out when to consider restarting
medication such as desmopressin.

The Trust has also set up a Task and Finish Group to review the feasibility of
cohorting patients needing the highest acuity of care, (which would include those
patients who need regular blood tests), with the ambition that these patients are
placed in a specialist ward area from April 2019 to facilitate more regular reviews of
their management. Care View, an electronic handover system which allows high risk
patients and their management plans to be communicated more effectively is also to
be introduced to AMU.

There has also been a review of the work patterns of Consultants working on the
Acute Medical Unit and the Trust now requires AMU Consultants to work on AMU on
at least two consecutive days in order to improve the continuity of care for AMU
patients.

Recommendation 3 of the RCA report also sets out that the Trust will be ensuring
that adherence to the policy for the Management of the Acutely Ii! Patient is
monitored at the divisional Morbidity and Mortality meetings.

Great care to every patient, every day
Patient Advice and Liaison Service (PALS) 020 8296 2508 | Main Switchboard 020 8296 2000
Chairman Laurence Newman | Chief Executive Daniel Eikeles

3. Concerns 3 and 5 - There was a failure to assess Mrs Taylor's fluid balance and to
understand that prescribing intra venous fluids with potassium is not an appropriate
method to increase serum potassium levels.

Response - The updated guidance on the management of hyponatraemia will set out
the importance of ensuring that patients with hyponatraemia have regular monitoring
of their fluid balance charts.

The Trust has also set up a Task and Finish Group to review the process for
managing the fluid balance charts of all patients in the Trust and a programme of
training will be introduced following this review - see Recommendation 7 of the Action
Plan.

4, Concern 3 — There was a failure to reintroduce desmopressin for Mrs Taylor.

Response - Recommendation 5 of the Action Plan sets out that; ‘Desmopressin
should be notified as a high risk drug that should not be discontinued without
specialist advice.’ The specialist providing the advice to discontinue the drug will
ensure that there is a plan in place to reintroduce the drug at an appropriate time.
This action has been implemented by the Medicines Management Committee with
input from the pharmacy department.

5, Concern 6 — There was a lack of documentation to ensure continuity of the patient's
care.

Response - The Trust is reviewing how we monitor compliance with our Health
Record Content policy which outlines the record keeping standards for Trust staff.
There are 14 standards set out within this policy which have been taken from the
guidance provided by the Royal College of Physicians. There will be a twice annual
audit of the 14 standards set out within the policy which will include an assessment of
the requirement to include ‘clear evidence of the arrangements made for future and
ongoing care’, The Joint Medical Director and Deputy Chief Executive has also
circulated a copy of the concerns raised in the Report to Prevent Future Deaths to ail
consultants within the Trust and has reminded them of their accountabilities around
the documentation of management plans and reminded them of the standards for
documentation set by the Royal College of Physicians.

6. Concern 7 — The Serious Incident Report did not fulfil its obligations and it was
agreed that a supplemental report would be prepared to reflect the circumstances of
Mrs Taylor's death and the learning points required to assist in preventing any future
deaths.

Response -E Associate Medical Director and Responsible
Officer, gave evidence in court that the Trust would be reviewing the concerns raised

during the inquest process and that we would be preparing a supplemental Root
Cause Analysis ’RCA’ report to address these concerns. A copy of the supplemental
RCA report is enclosed and we hope that you agree that the actions and
recommendations set out within the Action Pian of this report address the concerns
raised within your Report to Prevent Future Deaths.

Great care to every patient, every day
Patient Advice and Liaison Service (PALS) 020 8296 2508 | Main Switchboard 020 8296 2000
Chairman Laurence Newman | Chief Executive Daniel Elkeles

In order to support the sharing of learning from this incident the Joint Medical Director and
Deputy Chief Executive has presented the case at the Epsom Hospital Grand Round
meeting where she highlighted the learning and reflections from both the internal
investigation and the concerns raised in your Report to Prevent Future Deaths. In addition,
as detailed above

the Joint Medical Director and Deputy Chief Executive has also circulated a copy of the
concerns raised in the Report to Prevent Future Deaths and the Trust response to all

consultants within the Trust.

All of the clinicians who gave evidence at the inquest hearing have also reflected on the
conclusions of the Serious Incident investigation and have discussed the learning and
recommendations from the Root Cause Analysis investigation reports with the author of
the RCA who is also the Associate Medical Director.

| hope that this letter has provided you with assurance that your concerns have been taken
very seriously by the Trust and that our procedures and processes have been revised to

address those concerns.

We will share this letter with the family of Mrs Taylor and hope that it provides them with

some reassurance that the Trust now has systems and processes in place to ensure that
all patients with hyponatraemia will have a clear treatment plan to correct their sodium in
line with recognised guidance and that any risk of over rapid correction of hyponatraemia

will be avoided.

Yours sincerely,

Daniel Elkeles

Chief Executive
Epsom and St Helier University Hospitals NHS Trust

Great care to every patient, every day
Patient Advice and Liaison Service (PALS) 020 8296 2508 | Main Switchboard 020 8296 2000

Chairman Laurence Newman | Chief Executive Daniel Elkeles

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