Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0085, written 7 Mar 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Mar 2019 |
|---|---|
| Reference | 2019-0085 |
| Deceased | Chand Ali |
| Coroner | Alison Hewitt |
| 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.
Re : CHAND ALI DECEASED REGULATION 28 REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Director of Barts Heart Centre, St. Bartholomew’s Hospital 1 CORONER I am Alison Hewitt, HM Senior Coroner for the City of London. 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 I commenced an investigation into the death of Chand Ali on 14th December 2017. The investigation concluded at the end of the inquest on 28th February 2019. 4 CIRCUMSTANCES OF THE DEATH The Deceased was a 78 year old man who suffered severe, end-stage, heart failure and was diabetic. On the 7th July 2017 he attended the outpatient heart failure clinic at St Bartholomew’s Hospital for review and was found to have developed significant fluid overload and decompensated heart failure and, in consequence, at about 3pm he was admitted to Ward 6D of the hospital. Upon admission and over the following hours the Deceased was alert and responsive. At about 5.20 pm he was given an intra-venous dose of cyclizine, an antiemetic which, according to the British National Formula, must be used with caution for patients suffering severe heart failure. At about 6.45 pm he was found to have a low blood glucose level and this was treated with the provision juice and food, which he drank and ate, and the administration of glucogel. Subsequently, at about 7.20 pm, he was found to be unresponsive and his death was pronounced at 7.50 pm. On the balance of probabilities the Deceased’s death resulted from his decompensated heart failure. The possibility that the dose of cyclizine contributed to the heart failure and death cannot be ruled out but, on the evidence available, could not be said to be probable. The medical cause of death was : Ia Decompensated Heart Failure Ib Ischaemic Heart Disease II Chronic Renal Failure, Diabetes My conclusion as to the death was : Natural Causes 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 as a result unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows : As stated above, cyclizine is an antiemetic which, according to the British National Formula, must be used with caution for patients suffering severe heart failure, especially if it is administered intra-venously. The evidence revealed that cyclizine is administered to heart failure patients at St. Bartholomew’s Hospital, including those suffering severe heart failure, as the routine or standard antiemetic and without consideration of its likely effect on the individual patient in question. There is no system in place in the hospital requiring the prescriber to balance any risk to the patient arising from the use of cyclizine against the patient’s clinical need for it, in order to justify its prescription. Further, whilst it was said that the Hospital was not aware of any pattern or trend of deaths following the administration of cyclizine, it was accepted that the actual incidence of such deaths was not, in fact, known. It was accepted that monitoring and analysis of all deaths following the recent use of cyclizine would be needed in order to establish a reliable picture. It was also apparent from the evidence that there had been no comprehensive review of other available antiemetics in order to explore whether there exists and effective alternative antiemetic which is not subject to a caution in the British National Formula as to its use. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths by addressing the concerns set out above and I believe 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 2nd May 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, to the following Interested Persons and to the other organisations listed below which may find it useful or of interest. (Son of the Deceased) 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. 9 7th March 2019 Alison Hewitt
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.
Date: 26/06/2019 Private and Confidential Ms Alison Hewitt HM Senior Coroner City of London Divisional Clinical Director Barts Heart Centre St Bartholomew’s Hospital West Smithfield London EC1A 7BE Switchboard: 020 3416 5000 Email: www.bartshealth.nhs.uk Dear Ms Hewitt RE: Chand Ali (deceased), Regulation 28 Report to Prevent Future Deaths. In response to this regulation 28 report our lead pharmacist for Barts Heart Centre, , has undertaken an extensive review of the evidence available to support the caution highlighted in the British National Formulary for use of Cyclizine in patients with severe heart failure along with consideration of alternative anti-emetics that are available for our use. I have enclosed caution is very limited and its validity to clinical practice remains questionable. He has considered the 3 alternative anti-emetic drugs commonly used in our hospital but each of these come with their own cardiac cautions and do not offer a suitable alternative to the use of cyclizine. report but in summary, he has identified that the evidence base for this As instructed, we will warn all our teams of the risks of cyclizine in heart failure patients. However, it is inevitable that cyclizine will still be used in some patients with heart failure as it may be assessed as the best option in many situations. Yours Sincerely Cardiology Consultant Divisional Director, Barts Heart Centre CC: Medical Director St Bartholomew’s Hospital , Chief Medical Officer, Barts Health NHS Trust 1
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