Prevention of Future Deaths reports · 2018
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 report | 12 Jun 2018 |
|---|---|
| Reference | 2018-0225 |
| Deceased | Rita Taylor |
| Coroner | Karen Henderson |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Epsom and St Helier University Hospitals NHS 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.
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
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| 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
See every Prevention of Future Deaths report matching Epsom and St Helier University Hospitals NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.