Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0354, written 16 Nov 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Nov 2018 |
|---|---|
| Reference | 2018-0354 |
| Deceased | Dawn Gill |
| Coroner | Mary Hassell |
| 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 extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Dawn Patricia GILL (died 02.06.18)
THIS REPORT IS BEING SENT TO:
1. Dr Alistair Chesser
Chief Medical Officer
Barts Health
Royal London Hospital
Whitechapel Road
London E1 1BB
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 12 June 2018, one of my assistant coroners, William Dolman,
commenced an investigation into the death of Dawn Patricia Gill, aged
33 years. The investigation concluded at the end of the inquest
yesterday. I made a determination that death was drug related, as
follows.
Dawn Gill was a long term drug user and took illicit drugs whilst in the
Royal London Hospital, on top of her prescription medication (which
included methadone), unintentionally causing her death. Having last
been seen between midnight and 12.30am on 2 June 2018, her room
was checked at 1am, 2am and later, but her presence on the floor under
a pile of clothes was not detected until approximately 10am, by which
time she had died. Hospital CCTV was never viewed. It is unclear at
what point detection might have saved her life.
1
4
CIRCUMSTANCES OF THE DEATH
The medical cause of death was:
1a methadone overdose.
5
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. Ms Gill was a long term drug user and, based on her history, was
likely to take illicit drugs whether she was in or out of hospital.
However, while she was in hospital, no nursing care plan was
made to take this into account, for example by acknowledging the
higher risk that it brought. One nursing sister was not even aware
that staff suspected Ms Gill of going off the ward to take drugs.
2. Ms Gill was prescribed methadone in hospital and died of a
methadone overdose, but her drug chart was not available at
inquest and appears to have been lost.
If the drug chart was lost during her life, then that has implications
for her care. If it was lost after her death, then that would not have
affected care but, how ever innocent the true explanation, it leaves
the trust open to an accusation of trying to cover up evidence.
When ever it was lost, its absence is very disappointing. The
Barts legal representative at inquest was unaware until I asked to
see it on the day that it was missing. He had taken on the file from
a colleague a week earlier. He noted that my coroner’s officer had
not provided the trust with the report of the post mortem
examination until the day before, so he had not known that death
was the result of a methadone overdose. This was because the
trust had not provided the statements requested. However, Ms
Gill had been found in her room on the ward surrounded by drug
paraphernalia, so it would have been evident to staff at the outset
that drug toxicity was a potential cause of death.
3. Ms Gill’s room was described as having been searched on
numerous occasions overnight, by more than one person, the first
time approximately half an hour after she had last been seen, yet
her presence under clothing on the floor was not detected until
10am the following day.
2
I heard nursing evidence that Ms Gill could not possibly have been
in her room at the time of searching, but with the benefit of the
CCTV it is now evident that she was.
4. Ms Gill was thought to have left the ward for a cigarette some time
before 12.30am, though she was not actually seen leaving. She
was wearing her night things. When her absence was discovered,
hospital security personnel were not alerted. They could have
viewed the CCTV. If they had done so, they would have realised
that she had never left the ward. Hopefully, this would have
prompted a redoubling of the search effort of the ward.
There was confusion about the circumstances when the missing
person policy should be followed. I was told that the policy is not
clear. The responsible nurse said it was in the back of her mind
to contact security and she did not know why she had not. The
sister in charge said that she would not contact security for the
first two hours. The director of nursing said the contact should be
immediate. The clinical site manager and the responsible nurse
disagreed about the nature of the conversation between them
regarding contacting security. Neither of them had made a note.
There seemed to be a lack of clarity.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 15 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
Care Quality Commission for England
3
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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
16.11.18
4
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.
15 January 2019 PRIVATE & CONFIDENTIAL Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London, N1C 4PP Dear Coroner Hassell 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 www.bartshealth.nhs.uk RE: Regulation 28: Prevention of Future Deaths Report – Dawn Patricia Gill Thank you for conveying your concerns to me by way of the above report. Barts Health NHS Trust had learned lessons following this case, and is confident that the changes planned and implemented will minimise the risk of recurrence. In response to the specific concerns raised: Ms Gill was long term drug user and, based on her history, was likely to take illicit drugs whether she was in or out of hospital. However, while she was in hospital, no nursing care plan was made to take this into account, for example by acknowledging the higher risk that it brought. One nursing sister was not even aware that staff suspected Ms Gill of going off the ward to take drugs. During her stay in hospital the wider nursing team and medical staff were aware of the suspicion of Ms Gill taking illicit drugs. She had been spoken to by the consultant and charge nurse and the senior nurse to advise this was not acceptable. However the nursing care plan could and should have been more explicit about this, and if it had been nursing staff would have been more aware of her behaviour and the attendant risks. All nursing teams in the hospital are being reminded of the importance of documenting the use of suspected use of illicit drugs in care plans, and of ensuring this information is part of the nursing handover. Ms Gill was prescribed methadone in hospital and died of a methadone overdose, but her drug chart was not available at inquest and appears to have been lost. After the coroners court we examined the CD drug register which showed that the prescribed does of methadone had been administered. The drug charts remain missing. If the drug chart was lost during her life, then that has implications for her care. If it was lost after her death, then that would not have affected care but, however innocent the true explanation, it leaves the trust open to an accusation of trying to cover up evidence. Whenever it was lost its absence is disappointing---Ms Gill had been found in her room surrounded by drug paraphernalia so it would have been evident to staff at the outset that drug toxicity was the cause of death. The Trust agrees that the inability to locate the drug chart after her death and in preparation for the inquest was a serious failure, and apologises for this. We have since examined the controlled drugs register, which has confirmed that the prescribed doses of methadone in this case had been administered. The Trust accepts that the circumstances of this death made it even more important than usual that the prescribing chart was available after her death, and apologises for this failure. The Trust is moving in 2019-20 to electronic prescribing. This will eliminate the need for paper based drug charts, and the attendant risk of them being mislaid or lost. We were aware of her drug habit but we did not see her before her death so would have not have had chance to make any diagnosis or therefore suspected a drug overdose going forward all such patients we will suspect a potential for taking non prescribed drugs and treat accordingly but do not have the powers to stop such patients leaving the ward of their own free will. Ms Gill’s room was described as having been searched on numerous occasions overnight, by more than one person, the first time approximately half an hour after she had last been seen, yet her presence under clothing on the floor was not detected until 10am the following day. I heard nursing evidence that Ms Gill could not possibly have been in her room at the time of searching, but with the benefit of the CCTV it is now evident that she was. The fundamental problem was that the side room occupied by Ms Gill was crowded and too full of her own possessions, making it difficult for nursing staff to do their job. While the intention was well meaning, the tolerance of Ms Gill’s behaviour with respect to this matter was not in her best interests. All nursing staff have been reminded, through an anonymised vignette of this case, of the need to ensure rooms are kept tidy and organised. Clearly the checks of the room made by nursing staff during the night in question were not adequate in that they did not detect Ms Gill’s presence. The staff involved did not suspect Ms Gill was in her room and they have had feedback about the danger of making this assumption. The root cause of the problem though was that the room was not in an acceptable state and this obstructed the nursing team from performing an adequate visual inspection. Ms Gill was thought to have left the ward for a cigarette some time before 12.30am, though she was not actually seen leaving. She was wearing her night things. When her absence was discovered, hospital security personnel were not alerted. They could have viewed the CCTV. If they had done so, they would have realised she had never left the ward. Hopefully, this would have prompted a redoubling of search effort of the ward. There was confusion about the circumstances when the missing person policy should be followed. I was told that the policy is not clear. The responsible nurse said it was in the back of her mind to contact security and she did not know why she had not. The sister in charge said that she would not contact security for the first two hours. The director of nursing said the contact should be immediate. The clinical site manager and the responsible nurse disagreed about the nature of the conversation between them regarding contacting security. Neither of them had made a note. Ms Gill had been judged by the clinical team to have capacity to decide for herself whether she should leave the hospital or not under her own volition. The Barts Health Missing Person / Absconding Patient Policy is clear that this would not classify her absence as a “missing patient” but as a “self-absenting patient”. By this definition she was thought to have been a patient who had capacity, was not subject to legal detention, and who had left the hospital through her own choice, without clinical approval, with the intention of returning. In such circumstances the Trust policy states the Security team should not be called. However the policy recommends that if there is concern that the person may be missing “on Trust premises” then the Security team should be called. The problem here was that the staff did not suspect Ms Gill was on Trust premises, and they should have considered this. Our nursing teams have been reminded of the risks of making such assumptions as part of the learning from this case. Yours sincerely Chief Medical Officer Barts Health NHS Trust CC: , Medical Director, Royal London Hospital Legal Team, Barts Health NHS Trust
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