Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0018, written 11 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Jan 2019 |
|---|---|
| Reference | 2019-0018 |
| Deceased | Elizabeth Curtis |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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.
M. E. Voisin Her Majesty’s Senior Coroner Area of Avon 11th January 2019 REF: 10404 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: NHS Improvements Wellington House 133-155 Waterloo Road London SE1 8UG CORONER lam M E Voisin Senior Coroner for Area of Avon 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 19/04/2018 | commenced an investigation into the death of Elizabeth Rose CURTIS. The investigation concluded at the end of the inquest 24th October 2018. The conclusion of the inquest was Elizabeth Curtis was admitted into the Royal United Hospital, Bath on 17th March 2018 with a urinary tract infection and delirium; she was treated and prescribed antibiotics to treat the infection and Haloperidol to treat the delirium. She should have been prescribed 0.25mg but in fact was prescribed 2.5mg. of Haloperidol. The drug error was noted and the drug was stopped. Mrs. Curtis had a number of comorbidities including the fact she was 90, that she was frail, had chronic kidney disease, Crohn's disease and had a swallow problem. Mrs. Curtis developed aspiration pneumonia on 26th March and died on 31st March 2018 at Royal United Hospital Bath CIRCUMSTANCES OF THE DEATH Mrs Curtis died from aspiration pneumonia contributed to by a number of factors including: her age and frailty; her pre-existing underlying medical conditions; a problem with her swallow, an infection and delirium which required treatment with haloperidol. The drug haloperidol may also have had a minimal impact on her developing pneumonia. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion Telephone 01275 461920 Email AvonCoronersTeam @bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 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. — A patient’s mobility became an issue at the inquest and how this can help with assessing a patient’s wellness. | was advised vy at the Royal United Hospital, Bath, who gave evidence at this inquest that she was introducing to the hospital a mobility scale due to the impact that mobility or indeed frailty has on assessing well-being of patients when in hospital. , a. indicated that this is a simple scale noting a patient’s best mobility in the previous 24hrs. and is recorded alongside the NEWS score. Often mobility is the first symptom demonstrating a decline in health. | am told that the Royal United Hospital have adopted this scale. For further details in relation to this | would suggest that you contact Consultant Geriatrician, at Royal United Hospital NHS Foundation Trust her email is} | have also suggested that she write to you to outline her “mobility scale”, hence | have copied her into this report. ACTION SHOULD BE TAKEN In my opinion action should be taken. to prevent future deaths 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 a March 2019. |, 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 the deceased Royal United Hospital, Bath ‘Avon & Wiltshire Mental Health NHS Partnership Trust 1am also under a duty to send the chief coroner a copy of your response. The chief coroner may publish either of 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. 11/01/2019 Signature ME Voisin Senior Coroner Area of Avon Telephone 01275 461920 Email AvonCoronersTeam @bristol.gcsx.gov.uk Website www.avon-coroner.com The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
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.
8 March 2019 M E Voisin Senior Coroner for Area of Avon Dear Ms Voisin Re Elizabeth Rose Curtis NHS Improvement Wellington House 133 – 135 Waterloo Road London SE1 8UG T: 020 3747 0000 E: nhsi.enquiries@nhs.net W: improvement.nhs.uk Thank you for the Regulation 28 letter dated 11 January 2019 and sent to us via email with a cover letter dated 14 January 2019. I am replying on behalf of NHS Improvement. I am grateful to you for sharing your findings from the inquest with us and highlighting that action could prevent future deaths. In preparing this reply I have sought advice from the Royal College of Physicians and colleagues at NHS England to ensure we have identified all possible opportunities to do so. , who has kindly shared also spent time talking to We are grateful to you for putting us in touch with documents related to the mobility score she has developed. my teams about the mobility score and how they plan to use it within Royal United Hospital Bath NHS Foundation Trust. We have shared with to consider whilst locally testing the mobility score, including considering a format that does not use numbers and plus signs to reduce the risk of it being unintentionally added to the National Early Warning Score (NEWS2) and ensuring presentation helps ensure most recent mobility is not confused with required safe mobility. Improvement Patient Safety Collaborative for their support in assessing the impact of the initiative in her trust and for their support in potential future spread to other hospitals. some issues it would be important will link to her local NHS The Royal College of Physicians, who lead on the National Early Warning Score (NEWS2) are very supportive of the need to assess, monitor and act on a range of other signs and symptoms and test results that indicate a patient is either not improving as fast as expected or is getting unexpectedly less well. They believe this is best done by comprehensive assessment and review tailored to patient specialities alongside NEWS2, rather adding a mobility score as an additional field on NEWS2 charts nationally; but we will keep them updated on any significant findings from the work at Royal United Hospital Bath NHS Foundation Trust. Whilst we are not yet in position to use the local mobility score nationally, we are taking forward action to prevent future deaths related to the prescribing error that affected Mrs Curtis. Safe prescribing of haloperidol in acute hospital care can be challenging, as the doses that are appropriate for an older person with a lifelong history of a psychotic disorder differ from those appropriate to someone with delirium, and the dose that may be appropriate for using once to manage an emergency is different from a continued dose given regularly over days. This means that the standard limits within electronic Prescribing and Medication NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams. Administration (ePMA) systems* currently do not effectively block prescriptions that would be unsafe for a frail older person. However, the increasing sophistication of these systems means there is potential to do more to design out combinations of dose and duration that are outside prescribing guidelines for older people. We have asked our colleagues at NHS England and NHS Digital to work with the manufacturers of these systems and the trusts configuring them to consider building in prescribing limits that use a combination of dose and duration rather than dose in isolation, require an active decision to re-prescribe after 48 hours, and potentially restrict prescription of any repeat doses in older patients without authorisation from a senior or specialist member of staff. All hospitals within the NHS are moving towards the use of ePMA systems so this is likely to be the most effective route to ensure safer prescribing in the rare circumstances where haloperidol is needed to reduce distress from delirium. Some of our wider initiatives will also help improve the safety of older patients with similar needs to Mrs Curtis. Our Patient Safety Collaboratives support the development and sharing of best practice in identifying deteriorating patients, and they will support further improvement activities related to medication safety for older people in the coming year. Initiatives to encourage non-medical prescribing mean that specialist nurses, after appropriate training, can directly prescribe the medication they recommend, avoiding the risk of communication error when a doctor is asked to prescribe the recommended dose. Our quality improvement incentives for reducing risk of falls in hospital include avoiding prescription of medication like haloperidol in older patients unless strictly necessary. The NHS Long Term Plan describes how we will improve the care we provide to people with dementia and delirium and frailty, whether they are in hospital or at home. We appreciate that at the inquest you were made aware of additional local safety actions taken forward by Royal United Hospital Bath NHS Foundation Trust. Those including changes to prescribing systems, providing additional information for junior and locum doctors on the appropriate use of haloperidol, and review of consultant rotas and medical staffing levels. The regional team at NHS Improvement will continue to support the trust as it carries through these local actions. I hope you will be able to share my reply with Mrs Curtis’ family. I am very sorry indeed that these errors occurred when she became acutely ill and needed hospital admission, and I appreciate this must have been particularly distressing to her family when they had provided excellent support to enable her to live at home for so long. I hope it will give them some small comfort that we are taking steps to prevent future deaths, and I thank you for giving us the opportunity to do so. Yours sincerely Executive Medical Director and Chief Operating Officer NHS Improvement * Electronic Prescribing and Medication Administration (EPMA) refers to computer systems that guide safe and effective medication prescription and administration. NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams.
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