Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0306, written 23 Oct 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Oct 2018 |
|---|---|
| Reference | 2018-0306 |
| Deceased | Kalma Ram-Henman |
| Coroner | Veronica Hamilton-Deeley |
| Coroner area | Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Brighton and Sussex 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.
VERONICA HAMILTON-DEELEY DL,
LL.B.
Her Majesty’s Senior Coroner
for the City of Brighton & Hove
Assistant Coroners
CATHARINE PALMER LL.B (HONS)
GILVA D.J.TISSHAW, BA(LAW)HONS
THE CORONER’S OFFICE
WOODVALE, LEWES ROAD
BRIGHTON
BN2 3QB
Telephone: Brighton (01273) 292046
Fax: Brighton (01273) 292047
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CORONERS SOCIETY OF ENGLAND AND WALES
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
THIS REPORT IS BEING SENT TO:
1. Marianne Griffiths, Chief Executive, Brighton & Sussex University
Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road,
Brighton.
CORONER
I am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and
Hove
CORONER’S LEGAL POWERS
I 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 16th October 2018 I commenced an investigation into the death of Kalma RAM-
HENMAN, otherwise Kamla otherwise Kamala. The investigation concluded at
the end of the inquest on 16th October, 2018.The conclusion of the inquest was a
NARRATIVE CONCLUSION as per the attached sheet.
CIRCUMSTANCES OF THE DEATH
See Record of Inquest
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) This lady arrived in A&E in a “precarious” state as the blood test results
revealed and there were several failings:-
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VERONICA HAMILTON-DEELEY DL,
LL.B.
Her Majesty’s Senior Coroner
for the City of Brighton & Hove
Assistant Coroners
CATHARINE PALMER LL.B (HONS)
GILVA D.J.TISSHAW, BA(LAW)HONS
THE CORONER’S OFFICE
WOODVALE, LEWES ROAD
BRIGHTON
BN2 3QB
Telephone: Brighton (01273) 292046
Fax: Brighton (01273) 292047
The attending Doctor required an accurate fluid chart. This was started. It
was incompletely filled out and showed no output and no attempts were
made to measure any output. As a result, Doctors and Nurses were unaware
of just how dehydrated Mrs RAM-HENMAN was becoming.
(2) An ECG was ordered which showed abnormalities likely associated with her
low potassium level. This was not seen by the doctor who requested it.
The signature on it is illegible.
A second ECG should have been requested. It was not.
She was written up for potassium in A&E as well as intravenous fluids but
was given no potassium and only half a litre of intravenous fluids in her entire
24 hour admission.
It was the view of the Doctors giving the evidence that she should have
received at least four litres to deal with her depleted state. So instructions
given within three to four hours of her arrival in A&E (at 12.12pm on
6/6/2018) were not implemented.
Why not?
(3) Opportunities to realise that sodium and fluids had not been administered
were missed overnight when Mrs RAM-HENMAN was transferred from A&E
to Bristol Ward and was seen in the early hours of the 7th. It seems her
notes were not read so the failure to give fluids and potassium was missed.
(4) On the morning of the 7th at around 10.30 am. the attending Doctor wanted
Mrs RAM-HENMAN to be given Cyclazine, intravenous fluids and for her to
have a CT scan. None of this was achieved before her death two hours
later.
She should have at least received the intravenous fluids and the Cyclazine.
Again it seems that at this stage there was a failure to realise that she had
not been given the Potassium she had been written up for in A&E.
(5) Mrs RAM-HENMAN only had one set of bloods done. At Inquest I was told
that she should have had more bloods for comparison. These would
undoubtedly have shown her deteriorating condition and would have acted
as an additional reminder of the failings in her care.
(6) It may be that her transfer from A&E to Bristol Ward at around 5.30 –
6.30pm on the afternoon of the 6th June (a Thursday) coincided with a time
of hiatus on the ward but there should not have been an assumption that
she should simply be put in a bed and left until the morning ward round and
as I say it seems there was an opportunity missed when she deteriorated in
the night and a doctor was asked to see her.
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VERONICA HAMILTON-DEELEY DL,
LL.B.
Her Majesty’s Senior Coroner
for the City of Brighton & Hove
Assistant Coroners
CATHARINE PALMER LL.B (HONS)
GILVA D.J.TISSHAW, BA(LAW)HONS
THE CORONER’S OFFICE
WOODVALE, LEWES ROAD
BRIGHTON
BN2 3QB
Telephone: Brighton (01273) 292046
Fax: Brighton (01273) 292047
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(7) It transpires that Mrs RAM-HENMAN had a large gastric ulcer which
perforated. This in itself is a life threatening emergency and her presentation
was unusual.
From the evidence I heard it was clear that although there is no guarantee
that she would have survived the perforation, had she been optimised in
terms of fluids and Potassium her cardio vascular reserve would have been
considerably better.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I 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 15th January 2019. I, 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
1.
2.
3.
4.
Acute Medical Consultant, Royal Sussex County Hospital
, Consultant in Diabetes and Endocrinology, Royal Sussex
County Hospital
Medico-Legal Services Manager, Royal Sussex County
Hospital
Brighton and Hove Clinical Commissioning Group
5.
6.
7. Secretary of State for Health, Department of Health
8. Simon Stevens, Chief Executive, NHS England
Care Quality Commission
Who may find it useful or of interest.
I 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.
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VERONICA HAMILTON-DEELEY DL,
LL.B.
Her Majesty’s Senior Coroner
for the City of Brighton & Hove
Assistant Coroners
CATHARINE PALMER LL.B (HONS)
GILVA D.J.TISSHAW, BA(LAW)HONS
THE CORONER’S OFFICE
WOODVALE, LEWES ROAD
BRIGHTON
BN2 3QB
Telephone: Brighton (01273) 292046
Fax: Brighton (01273) 292047
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Date: 23rd October 2018 SIGNED BY:
HM Senior Coroner Brighton and Hove
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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.
NHS Brighton and Sussex University Hospitals NHS Trust Brighton and Sussex University Hospitals NHS Trust Trust Headquarters Royai Sussex County Hospital Eastern Road Brighton BN2 5BE Our Ref: gfimf Miss Veronica Hamilton Deeley HM Senior Coroner Brighton and Hove The Coroner's Office Woodvale Lewes Road Brighton BN2 3QB 30 January 2019 Dear Miss Hamilton Deeley Mrs Kalma (Kamla) Ram-Henman deceased | am writing in response to the Regulation 28 Report which was issued following the inquest for Mrs Ram-Henman. | am grateful to you for having extended the deadline for response, in order that we could complete discussions concerning the Action Plan, as part of the Serious Incident (SI) investigation process. | attach a copy of the SI report for information, a copy of which will be sent to Mr Ram-Henman. | would first like to express my condolences to Mr Ram-Henman and his family and friends for their very sad loss. Mrs Ram-Henman’s death was a tragic event which has deeply affected all the staff involved. | am very sorry that there were inadequacies in Mrs Ram-Henman’s care which compromised her ability to withstand a perforated gastric ulcer. | know that these events were shocking and distressing for Mr Ram-Henman and his family. Following the inquest, discussions took place in team meetings for the clinical specialities involved, involving medical and nursing staff, to ensure that staff awareness of the learning issues took place as soon as possible. The inquest findings were reviewed at the Trust’s Serious Incident Review Meeting, chaired an Deputy Medical Director: Safety and Quality, and this concluded that an SI investigation should be undertaken. In addition, a General Medicine Morbidity and Mortality Meeting has taken place, also attended by senior clinical staff from the Emergency Department (ED), to review the issues arising from Mrs Ram-Henman’s care. The attached SI report contains the Action Plan with timescales for implementation of the measures agreed. As you will see, we have implemented a new SBAR telephone handover form (copy attached for reference) as part of the revision of the Emergency Department Safety Booklet. The form includes prompts for staff on drains and lines present, and medication issues. In the longer term, the implementation of an Electronic Prescribing System will ensure that the problems that occurred with administration of Mrs Ram-Henman’s fluids and potassium will not happen again and we estimate that the new system will be in place in approximately 18 months. The S| investigation also showed that it has been habitual for some staff to use the “once-only” section of the drug prescription chart, when prescribing fluid/drug infusions. This section was designed to be used by ED clinicians who may need to prescribe antibiotics for patients with a suspected chest infection or who need pain relief, who are then discharged from ED. It is not appropriate to use this section for IV infusions and a Trust Safety Alert has been issued, instructing all staff not to use this section of the drug chart for infusions and that any such prescription should be completed in the normal section of the drug chart. A prompt will also be added to the front of the drug chart, reminding staff of this requirement. During review of Mrs Ram-Henman’s care, it was also noted that at the time of her admission to the ward a member of the pharmacy team documented their review of previous drug history but there was no documentation concerning review of ongoing drugs prescribed. The relevant Lead Pharmacist will discuss this with the member of staff concerned and with the wider team to emphasise the importance of documenting such reviews in the patient records. Fini) Consultant in Acute Medicine and Clinical Lead for Ambulatory Care, has implemented a new system whereby an Acute Medicine Consultant will cover telephone calls whilst another Acute Medicine Consultant sees patients when requested. This will ensure that the Consultant seeing patients is released from answering calls and will allow more time for review and follow up of clinical plans. | hope this letter is helpful in addressing the concerns you raised but if you need any further information please do not hesitate to contact me. 1 would be grateful if you could pass on my apologies iim... his family for those aspects of Mrs Ram-Henman’s care which fell below the standard which we expect and for all the distress this has caused. Yours sincerely Dr George Findlay Chief Medical Officer and Deputy Chief Executive cc. Serious Incident investigation report Telephone handover form
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