Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0284, written 14 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Sep 2018 |
|---|---|
| Reference | 2018-0284 |
| Deceased | Paul Ryley |
| Coroner | Emma Brown |
| Coroner area | Birmingham and Solihull |
| Category | Alcohol, drug and medication related deaths |
| Organisation named | Birmingham and Solihull Mental Health NHS Foundation 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Toxbase
CORONER
{am Emma Brown Area Coroner for Birmingham and Solihull
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.
INVESTIGATION and INQUEST
On 15/06/2018 | commenced an investigation into the death of Paul David Ryley. The investigation
concluded at the end of an inquest on 11th September 2018. The conclusion of the inquest was of an
Alcohol and drug related death.
CIRCUMSTANCES OF THE DEATH
The Deceased died at the Birmingham Heartlands Hospital at 11:36 on the 14th April 2018 as a result of
the effects of a paracetamol overdose on the 10th April 2018. He had attended hospital on the 10th April
at which time he showed no clinical symptoms of paracetamol toxicity and his plasma concentration was
below the treatment threshold. However, he presented again on the 11th April with persistent
tachycardia, lower stomach pain, episodes of nausea and vomiting and visual hallucinations, routine
blood tests were not undertaken and his symptoms were attributed to alcohol withdrawal despite a
known risk that severe liver toxicity can develop in a few patients with a plasma paracetamol level that
appears below the threshold. It is likely that routine blood test results would have been abnormal
resulting in diagnosis and treatment which would have given a 50% chance of success. By the time he
was admitted on the 12th April the deceased was too ill for treatment. The Deceased’s intention when
he overdosed on the 10th April cannot be identified on a balance of probabilities.
Following a post mortem the medical cause of death was determined to be:
ta) PARACETAMOL INDUCED LIVER INJURY
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. The Toxbase Guidelines for Paracetamol overdose {which compromise of a general guidance
sheet and then several sheets specific to the period since ingestion) were considered and it was
identified that they do not expressly state whether or not they apply only to an initial
attendance and do not set out any steps to be followed when a patient re-presents within a
short time of an initial attendance for a Paracetamol overdose.
2. Evidence was heard from an ED Registrar, ED Consultant and the Consultant Hepatologist that
lead the Trust’s root cause analysis investigation that the guidelines are commonly understood
by emergency department practitioners within this Trust and elsewhere to be applicable only to
the patient’s initial attendance and are therefore not considered when a patient re-attends even
when that re-attendance is within days (in this case within 24 hours) of the initial attendance.
Evidence from the experienced ED Consultant was that this is what she had understood from
local and national training.
3. The evidence before the court was that it is, or ought to be, known that despite a plasma
paracetamol level below the therapeutic threshold patients can go on to suffer liver toxicity
following a paracetamol overdose and this is clearly stated within the Toxbase guidance.
4. In this case the clinicians did not refer to the Toxbase guidance when the Deceased represented
other than to check that on his initial presentation his plasma paracetamol level had been below
the therapeutic level (which it had been).
5. The evidence of a Consultant Hepatologist at the inquest was that he could not foresee any real
risk in practice from following the guidance within the applicable Toxbase sheet based on time
since ingestion even on a representation and to do so would in some cases result in treatment
and avoid death.
6. There is therefore a risk that patients are not being given treatment that would increase their
chances of survival because clinicians do not have clear guidance on what to do when a patient
re-presents and do not regard the existing guidance as applicable.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths in the form of review the existing Toxbase
guidance and how it is used with respect to re-presentation for paracetamol overdose 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 g"
November 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
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family
of Mr. Ryley, the University Hospital of Birmingham NHS Foundation Trust, West Midlands Police and
Birmingham and Solihull Mental Health NHS Foundation Trust. | have also sent it to NHS England who
may find it useful or of interest.
| 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.
14/09/2018
Signature
Emma Brow! Coroner Birmingham and Solihull
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.
Subject: RE: * FW: Matter ot Paul David Ryley - Report to Prevent Future Deaths Dear Ms Boyle Paul David Ryley The NPIS has now been able to examine the evidence you provided about this case, as well as our own records which include details on use of the TOXBASE database by registered NHS users including the Emergency Department that managed Mr Ryley.. Specifically in relation to the advice on TOXBASE and its use by this hospital: The patient presented 10 April 2018 at 10.47. Dr Benson reviewed the patient at 12.15 and again at 12.54. The TOXBASE management page for paracetamol was accessed by that Emergency Department at 12.47. We cannot guarantee that TOXBASE was accessed with respect to this specific patient but given the timings it does seem likely. The patient re-presented on 11 April 2018 at 11.12. Dr Wijendra reviewed the patient at 12.21. The (appropriate)TOXBASE management page for patients presenting more than 24 hours after ingestion was accessed by the department at 12.18. The printable page was also accessed at this time. Again, we cannot guarantee it was accessed with respect to this patient but it does seem likely given the matched timings. There is a very small possibility of another patient presenting more than 24 hour after ingestion of paracetamol being managed in the same department at the same time. Within this TOXBASE entry for patients greater than 24 hour after ingestion the advice clearly presented in point 2 is to check all bloods. TOXBASE guidance for acute paracetamol overdose is clearly set out for different time intervals after ingestion. There is no suggestion that advice would apply only to an initial presentation, contrary to assertions made during the inquest. Also, the NPIS provides a 24/7 telephone advice line that health professionals can use if they are uncertain as to the management of a patient who may have been poisoned. Nevertheless, in view of the coroner’s advice, we have added a further statement to the paracetamol index in’ our TOXBASE guidance as follows. if the patient re-presents following assessment and discharge, manage as per a new presentation. We hope that the information provided is useful and that the actions we have taken deal adequately with the coroner's Regulation 28 Report. Yours sincerely Simon Thomas Chair, NPIS Clinical Standards Group
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