Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0002, written 29 Apr 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Apr 2019 |
|---|---|
| Reference | 2019-0002 |
| Deceased | Steffan Kuenzel |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Coroner ME Hassell HM Senior Coroner Inner North London REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Clinical Director Bart’s Health NHS Trust Ground Floor, Pathology and Pharmacy Building, The Royal London Hospital, 80 Newark Street, London, E1 2ES 1 CORONER I am: Assistant Coroner Sarah Bourke Inner North London Poplar Coroner’s Court 127 Poplar High Street London E14 0AE 2 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. 3 INVESTIGATION and INQUEST On 14 November 2018, Senior Coroner Mary Hassell commenced an investigation into the death of Steffan Kuenzel aged 45 years. The investigation concluded at the end of the inquest which was conducted by me on 28 February 2019. The conclusion of the inquest was that Mr Kuenzel’s death was alcohol related. The medical cause of death was: 1a hypertensive heart disease and alcoholic fatty liver disease My short form conclusion was that “Mr Kuenzel had a cardiac arrest following a 10 day period of alcohol withdrawal. He died at the Royal London Hospital on 11 November 2018”. 4 CIRCUMSTANCES OF THE DEATH Mr Kuenzel had longstanding problems with alcohol. Initially he was a binge drinker but his pattern of drinking had become more regular following episodes of alcohol related seizures. He had had a number of detoxes in the past but had relapsed on each occasion. He had contacted the RESET service but had problems in engaging due to the service’s requirement that he take steps to address his drinking in the community before funding could be authorised for a further detox. His last contact with RESET was in December 2017. He was admitted to the Royal London Hospital in May and August 2017 with alcohol related withdrawal seizures. His last hospital admission was in September 2018. On each occasion, he was advised to reduce his alcohol consumption gradually in order to avoid seizures and problems with alcohol withdrawal. He was not given any guidance as to how he should reduce his alcohol consumption. His partner’s evidence was that he was drinking 1 litre of vodka per day in August 2018. He reduced this to 750 ml per day for a month. At the end of October 2018, he reduced from 750 ml per day to 375 ml per day. Around this time, he became very weak and unwell with dizziness, vomiting and diarrhoea. He last had an alcoholic drink on 1 November 2018 as he felt too unwell to drink. His symptoms continued for over a week. On 10 November, he was a little better and was able to eat. In the early hours of 11 November, he woke his partner complaining of feeling unwell. He then lost consciousness and started snoring. His partner called for an ambulance. During the course of the call, Mr Kuenzel stopped breathing. Paramedics attended but were unable to resuscitate Mr Kuenzel. He was taken to A&E at the Royal London Hospital where his death was confirmed shortly after 2 am. A post‐mortem examination was undertaken by . Toxicology analysis had found that there were no traces of alcohol in Mr Kuenzel’s system. noted “The most significant findings on autopsy examination were in the heart and lungs. The heart was mildly enlarged, with left ventricular hypertrophy, consistent with hypertensive heart disease. In addition, both lungs were severely congested and microscopic examination demonstrated severe pulmonary oedema, with pigment‐laden macrophages, consistent with changes secondary to cardiac failure. There was severe steatosis of the liver, consistent with alcoholic fatty liver disease … Severe steatosis of the liver can cause electrolyte imbalance which, in turn, predisposes patients to cardiac arrhythmias… The exact contribution of alcohol withdrawal cannot be confirmed, although sudden alcohol withdrawal is reported to contribute to the likelihood of arrhythmias, due to electrolyte disturbance”. 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 could 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 decline in Mr Kuenzel’s health appears to coincide with the reduction from 750 ml vodka per day to 375 ml. Mr Kuenzel had attended hospital with alcohol withdrawal related seizures on a number of occasions. He was advised to gradually reduce his drinking but not given any specific advice as to how this should be done. Whilst alcohol reduction is most safely undertaken with the support of specialist agencies, there will be some people who present at hospital with serious alcohol withdrawal related problems that will not engage with services. Those individuals may develop withdrawal related problems through deciding to reduce their alcohol consumption independently. 2) The deterioration in Mr Kuenzel’s health from late October 2018 may be attributable to alcohol withdrawal. Mr Kuenzel and his partner knew that he needed to seek medical attention if he had a seizure but did not know of any other signs or symptoms of alcohol withdrawal which would require urgent medical treatment. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 24 June 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 Chief Coroner and to the following Interested Persons aseda (partner) 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. Sarah Bourke Assistant Coroner 29 April 2019
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.
Royal London Hospital Room 124, 1st floor John Harrison House London E1 2DR PA Direct Line: 020 3594 6979 www.bartshealth.nhs.uk Sarah Bourke Assistant Coroner Poplar Coroners Court 127 Poplar High St E14 0AE 13 June 19 Dear Sarah Thank you for taking my call on Thursday and our discussion regarding the death of Steffen Kunzel. Looking through our electronic notes he had an admission relating to his alcoholism in August 2017. This lead to various investigations and treatments but importantly a referral to Reset to support his attempts to reduce his alcohol intake. I enclose a snapshot of his discharge summary from this. He was also seen in ED later in September of that year, it was noted that he had been referred to the alcoholic community support- I enclose again an image of his electronic discharge. He then didn’t present to us for another 12 months, which was a single attendance in ED, with alcohol intoxication. Again he was treated, stayed a few hours and felt well enough to leave. He wasn’t seen again until his final collapse later that year. Discussing with our ED department they thought it likely that it was noted from his past CRS record that he was under an alcohol reduction scheme in the community but it’s not documented if this was discussed with him. As he was intoxicated it may have been difficult to obtain a good history. We both agree that alcohol addiction is a serious public health issue ; we have many attendances each week with alcohol related conditions . Discussing with our alcohol team they have too little resource to provide support for every attendance and concentrate on those admitted to the hospital. Our public health consultant, Ian Basnett is currently working on improved health care packages for our alcoholic patients-this follows successful packages for our smokers Mr Kunzel only had one attendance to ED in 12 months which would not have triggered a further referral .As above our public health team is looking at ways of offering more information to these patients but they are a difficult group with a very varied pattern of attendance and compliance On balance we could offer contact details of various agencies; how useful this would be at the time of presentation I am unsure. From the little of his GPs electronic notes I can see there is very little covering his addiction. I will do a formal response to the PFD if necessary but this covers the enclosed hospital documentation following our conversation Yours sincerely Consultant Anaesthetist Medical Director RLH Responsible Officer Bart’s Health
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, 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.