Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0161, written 10 May 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 May 2019 |
|---|---|
| Reference | 2019-0161 |
| Deceased | Karanbir Cheema |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths (PFD) report
Karanbir Singh CHEEMA (died 09.07.17)
THIS REPORT IS BEING SENT TO:
1.
Executive Head Teacher
William Perkin High School
Oldfield Lane North
Greenford UB6 8PR
2. Dame Jacqueline Docherty
Chief Executive
London North West University Healthcare NHS Trust
Ealing Hospital
Uxbridge Road
Southall UB1 3HW
3.
Medical Director
London Ambulance Service
220 Waterloo Road
London SE1 8SD
4. Ms Heather Bresch
Chief Executive
Mylan Pharmaceuticals
Trident Place
Building 4
Mosquito Way
Hatfield AL10 9UL
5.
6.
President
British Society for Allergy and Clinical Immunology
Studio 16
Cloisters House
8 Battersea Park Road
Nine Elms
London SW8 4BG
President
Royal College of Paediatrics and Child Health
5-11 Theobalds Road
Holborn
London WC1X 8SH
1
7. Professor Dame Sally Davies
Chief Medical Officer for England
Department of Health and Social Care
Room 114, Richmond House
79 Whitehall
London SW1A 2NS
8. Mr Matt Hancock MP
Secretary of State for Health and Social Care
Department of Health and Social Care
9. Mr Damian Hinds MP
Secretary of State for Education
Department for Education
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 July 2017 I commenced an investigation into the death of Karanbir
Cheema, aged 13 years. The investigation concluded at the end of the
inquest today. I made a narrative determination at inquest, which I attach
to this letter.
4
CIRCUMSTANCES OF THE DEATH
Karanbir was attended William Perkin High School. On Wednesday, 28
June 2017, another pupil threw a small piece of cheese at him. He was
known to be allergic to cheese and he went into anaphylactic shock.
2
His medical cause of death was:
post cardiac arrest syndrome
anaphylactic shock
1a
1b
1c multiple food allergies
bronchial asthma
2
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.
I am aware that some changes have been made since Karanbir’s death
and therefore do not need to be re-iterated now, but others remain
outstanding. Some issues I raised before Karanbir’s death, in PFD
reports I made in May 2017 following the death of Nasar Ahmed on 14
November 2016.
The MATTERS OF CONCERN are as follows.
1. The pupils at Karanbir’s school had a patchy understanding of his
allergies, what they were and the consequences of exposure to
allergens. Targeted education about this would improve safety.
2. Karanbir’s school care plan and medical box were not checked or
audited to ensure, for example, that if his care plan stipulated two
EpiPens® (adrenaline auto-injectors), the box contained two
EpiPens.
3. Karanbir’s EpiPen was out of date. There must be systems in
place to ensure that medication in schools is in date.
4. Allergy action plans are not standardised across hospitals and
schools, so messages are not as clearly delivered as they could
be. This is vital particularly when they may be read for the first
time in a desperate situation where panic has set in.
5. The allergy action plan drafted by Karanbir’s doctors at Ealing
Hospital did not find its way to his school. There is no
standardised approach to this, for example always sending a copy
to the school designated safeguarding lead, as well as giving
parents/carers a copy for themselves and a copy for the school in
case the posted version does not arrive.
3
6. Karanbir’s treating doctors wanted him to re-attend for asthma
and allergy review four months after his last consultation. An
appointment was made but cancelled by the hospital. By the time
of his death four months later he had still not been seen again.
There needed to be recognition of the time critical nature of this
appointment. It needed to be re-booked without delay.
7. Karanbir had one EpiPen at home, one at school and one at his
father’s home. There is clearly a need for medical teams to
emphasise that two EpiPens must be available at all times.
8. There appears to be a lack of awareness nationally of the simple
but vital messages that:
-
-
if a person with an allergy has been exposed to an allergen
and develops any respiratory compromise, so any breathing
difficulty at all, then adrenaline (via EpiPen or other) should be
administered immediately, before any asthma pump and even
before calling for help;
if there is a deterioration after giving one EpiPen, then another
should be administered immediately, or in any event after five
minutes if there is no improvement.
9. The EpiPen box does not contain these instructions on the
outside.
10. These instructions were not communicated effectively as part of
the school staff’s first aid and EpiPen training.
11. The London Ambulance Service 999 operator did not at any time
suggest that a second EpiPen be given, because this is not
contained within the algorithm. That could be remedied
internationally.
12. The allergy specialist who gave evidence was firmly of the view
that generic adrenaline auto-injectors should be available, in
much the same way as defibrillators, in public spaces.
This was the view of the respiratory physician who gave evidence
in May 2017 and about which I wrote then to the Chief Medical
Officer for England. Is this worthy of reconsideration?
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.
4
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 8 July 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
Medicines and Healthcare Products Regulatory Agency
Association of Ambulance Chief Executives (AACE)
National Ambulance Service Medical Directors (NASMeD)
Health and Safety Executive
Safeguarding Children Board
Child Death Overview Panel
, Karanbir’s mum
Karanbir’s dad
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
10.05.19
5
2 responses 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.
London Ambulance Service INHS| NHS Trust Legal Services Headquarters 220 Waterloo Road London Ms Mary Hassell SE1 8SD Inner North London Tel: 0207 783 2001 St Pancras Coroners Court Fax: 0207 783 2009 Camley Street www.londonambulance.nhs.uk neon Your Ref : Our Ref : 2361 Date : 1 July 2019 Dear Ms Hassell, Regulation 28: Prevention of Future Deaths Report- Karanbir Cheema Thank you for your Regulation 28 Prevention of Future Deaths (PFD) report dated 10 May 2019. The Trust welcomes your recommendation for changes to prevent future deaths and | would like to take the opportunity at the outset of my letter to offer my sincere condolences to Karanbir Cheema’s family. The matter of concern you raised at the inquest is as follows: The London Ambulance Service 999 operator did not at any time suggest that a second EpiPen be given, because this is not contained within the algorithm. That could be remedied internationally. In the United Kingdom there are two 999 call triage systems; NHS Pathways and Medical Dispatch Priority System (MPDS). The London Ambulance Service NHS Trust (LAS) processes 999 calls via MPDS which is devised by the International Academy of Emergency Dispatch (IAED). As you are aware, under the terms of the licence to use MPDS the LAS as a licenced user does not have jurisdiction to make changes to the call taking protocols unilaterally and must submit requests for change to the Standards Committee of the IAED. | am advised by our Chief Medical Officer that this PFD was raised at the UK Clinical Focus Group for IAED-MPDS on 22 May 2019 and has also been raised with the Executive Director of mPDS The group welcomed this recommendation and we await their conclusion/outcome. Our Chief Medical Officer has taken the opportunity to share this PFD with a .. Chair for The National Ambulance Service Medical Directors (NASMED) for their consideration who will raise it with the Association of Ambulance Chief Executives (AACE). As the Trust is also a NHS 111 provider for integrated urgent care, this PFD has also been raised with| the Chair of NHS Pathways National Clinical Governance Group and i the NHS Pathways Deputy Clinical Director. a a; confirmed that NHS Pathways advises to give another dose if there is no improvement after the first dose and states that “If the individual's condition does not improve adrenaline should be repeated if available after 10-15 minutes, according to the manufacturer's instructions”. | hope this reply is helpful in explaining the actions taken to address the matter of concern. Yours sincerely Garrett Emmerson Chief Executive
f= Gd Putting patients INHS| Sy atthe TRARY London North West f hi d P ° — University Healthcare NHS Trust Coroner ME Hassell 1} ih Wa Trust Headquarters Senior Coroner la ws ieee ond Northwick Park Hospital Inner North London Wy wm 2 JUL avis bed Watford Road St Pancras Coroner's Court _ _ Harrow Camley Street cme msi Middlesex London REESE HA1 3UJ N1C 4PP www.|nwh.nhs.uk 1 July 2019 Dear Ms Hassell RE: Recommendations following the inquest of Karanbir Singh Cheema concluded on 10 May 2019. | write further to the conclusion into the inquest of Karanbir Singh Cheema wherein you raised 12 matters of concerns against nine organisations. Four of those concerns relate to the London Northwest University Healthcare NHS Trust namely: 1. (Point 4 of matters of concern listed in the Prevention of Future Death Report) Allergy action plans are not standardized across hospitals and schools, so messages are not as clearly delivered as they could be. This is vital particularly when they may be read for the first time in a desperate situation where panic has set in. 2. (Point 5 of matters of concerns listed in the Prevention of Future Death Report) The allergy action plan drafted by Karanbir’s doctors at Ealing Hospital did not find its way to his school. There is no standardized approach to this, for example always sending a copy to the school designated safeguarding lead, as well as giving parents / carers a copy for themselves and a copy for the school in case the posted version does not arrive. 3. (Point 6 of matters of concerns listed in the Prevention of Future Death Report) Karanbir’s treating doctors wanted him to re-attend for asthma and allergy review four months after his last consultation. An appointment was made but cancelled by the hospital. By the time of his death four months later he had still not been seen again. There needed to be a recognition of the time critical nature of this appointment. It needed to be re-booked without delay. 4. (Point 7 of matters of concerns listed in the Prevention of Future Death Report) Karanbir had one Epipen at home, one at school and one at his father’s home. There is clearly a need for medical teams to emphasise that two EpiPens must be available at all times. Trust Headquarters: www. |nwh.nhs.uk Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ Follow us on Twitter @LNWH_NHS T +44 (0)20 8864 3232 or like us on Facebook at London North West Healthcare You gave the Trust fifty six days to consider this issue and write to you setting out how the Trust proposes to address your concerns. The Trust has taken your concerns very seriously and has made the following changes: 1. Standardized allergy care plans Following this case, the paediatric allergy leads from Ealing and Northwick Park Hospital advise that they use and advocate the BSACI Allergy Action Plan for any child with an allergy — which is printed in colour from clinic and 2 copies are given to parents (one to be kept at home and one for them to share with the school nurse or welfare officer of the school), and this is shared with the GP and a copy is left in the clinical records. This information has been presented to the Paediatric team in the Departmental Clinical Governance meeting on 26 June 2019. Education and training of the use and administration of cetirizine and adrenaline auto-injector is given to the child at the same time as the action plan from clinic as point of care after identification of the allergy. To ensure this we will go through the allergy action plans and injection technique with the child (if age appropriate) and the carers in clinic always. 2. Sharing of the allergy care plan with the school | have been advised by the clinicians that the usual practice is training the parent (and child) first and informing them to tell the school of the child’s allergy and avoidance of the precipitant. Following Karanbir’s inquest, the Trust has added the additional process of posting or emailing each allergy plan to the school in question. 3. Re-booking cancelled clinics The relevant department has been advised that before a clinic list is cancelled (when there are patients already in the list), the clinician is given the list of patients of the clinic who then looks through to see if any of the appointments are “time critical’ (as it was in Karanbir’s case) and then instructs the secretary or access centre to send out the appropriate alternate date for the next appointment. 4. Availability of two adrenaline auto-injectors The Trust has made changes in that there will be two adrenaline auto-injectors to be kept with the child at all times and two to be kept at the school, so GPs will be asked to prescribe 4 adrenaline auto-injectors . The GP will be asked to prescribe 3 adrenaline auto-injectors if it is known that the school has a generic adrenaline auto-injector for use for any child. Simon Crawford Deputy Chief Executive On behalf of Jacqueline Docherty DBE Chief Executive Trust Headquarters: www.I|nwh.nhs.uk Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ Follow us on Twitter @LNWH_NHS T +44 (0)20 8864 3232 or like us on Facebook at London North West Healthcare
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