Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0214, written 24 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Jun 2019 |
|---|---|
| Reference | 2019-0214 |
| Deceased | Lewis Doyle |
| Coroner | Andre Rebello |
| Coroner area | Liverpool |
| Category | Railway related deaths |
| 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: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 The Secretary of State for Health and Social Care Ministerial Correspondence Department of Health and Social Care 39 Victoria Street London SW1H 0EU 2 NHS England NHS England, PO Box 16738, Redditch, B97 9PT england.contactus@nhs.net 3 NHS Improvement Wellington House, 133-155 Waterloo Road, London, SE1 8UG enquiries@improvement.nhs.uk 1 CORONER I am Andre REBELLO, Senior Coroner for the area of Liverpool and Wirral 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 17/01/2019 I commenced an investigation into the death of Lewis James Doyle aged 80. The investigation concluded at the end of the inquest on 24 June 2019. The conclusion of the inquest was: An accidental death The Medical Cause of death was I a Organising Pneumonia I b Traumatic injuries to feet (with distal amputations), severe coronary artery disease and metastatic carcinoma of the prostate I c II 4 CIRCUMSTANCES OF THE DEATH Mr Lewis James Doyle had a past medical history of Coronary Artery Disease, Parkinson’s disease, Cerebral meningioma, Adenocarcinoma of the prostate & a longstanding recurrent depressive illness (without psychosis) for which he was prescribed fluoxetine, mirtazapine and lithium. On 10th September 2018, Mr Doyle was admitted to Arrowe Park hospital following an episode of Acute Coronary Syndrome. On the 14th September 2018, a decision was made to suspend lithium medication, as the level was 1.4, which was biochemically toxic. On the 20th September 2018, the Lithium was stopped and later the same day Mr Doyle suffered a cardiac arrest. On 24th September 2018, Mr Doyle was transferred to Liverpool Heart & Chest Hospital where he underwent a procedure to insert coronary artery stents and an internal cardiac defibrillator before being discharged home. On 22nd October 2018, Mr Doyle was seen by his General Practitioner for a review of medication relating to his enlarged prostate. At 12.53 on the 22nd October 2018, Mr Doyle fell in front of a train at Bebington Railway Station. Mr Doyle was disorientated in thought and there is no evidence that he intended to self-harm. It is possible that he was experiencing a psychosis. Mr Doyle suffered head and lower limb injuries was taken to University Hospital Aintree where he underwent a bilateral foot amputation. On 30th October 2018 after a discussion between a Merseycare psychiatrist and a University Hospital Aintree cardiologist, the decision was made to re-introduce lithium to Mr Doyle. It is found that Lithium had to be stopped when it was at a toxic level and there were no alternatives for mood stabilisation, which did not carry a risk to his cardiac health. The Lithium was reintroduced when Mr Doyle was medically stable minimising the risk of a further cardiac event. On 17th November, once stable Mr Doyle was transferred to Arrowe Park Hospital to continue his treatment on the orthopaedic ward. During his time at Arrowe Park, Mr Doyle developed a chest infection for which he was treated with antibiotics, which were escalated when his symptoms worsened, he became breathless and his oxygen requirements increased. Chest X-Rays demonstrated pulmonary oedema & furosemide was then added to clear his lungs. On 8th January 2019, it appeared there was no clinical improvement and furthermore Mr Doyle was deteriorating. The decision was made to turn off the internal cardiac defibrillator to prevent painful & inappropriate shocks. Mr Doyle passed away and his death was confirmed at 20:58 on 8th January 2019. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) When Mr Doyle was discharged from the Liverpool Heart and Chest Hospital the GP discharge letter was sent to his GP. Mr Doyle was receiving treatment for Acute Coronary Syndrome but also mental health care for a Recurrent Depressive Illness (without Psychosis). Lithium had to be stopped not only because it was at a toxic level but also because of the effect of this and alternate medications on cardiac health. It occurred during the inquest that in similar scenarios better patient care could be delivered, if discharge letters were sent to all current medical attendants, whether in primary, secondary or tertiary care. Information with regarded to suspended or stopped medication was needed by the original prescribers. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 19 August 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: Mr Doyle’s family Wirral University Teaching Hospital Cheshire and Wirral Partnership I have also sent it to: Liverpool Heart and Chest Hospital The University Hospital Aintree Knowsley and St Helen’s NHS Foundation Trust The Royal Liverpool University Hospital Trust who may find it useful or of interest. 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 Andre REBELLO Senior Coroner for Liverpool and Wirral Dated: 24 June 2019
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.
a From Nadine Dorries MP Parliamentary Under Secretary of State for Mental Health, Department Suicide Prevention and Patient Safety of Health & Social Care 29 Vitoria Sect SW1H 0OEU Your Ref: 00123-2019 020 7210 4850 Our Ref: PFD-1188207 Mr André Rebello HM Senior Coroner, Liverpool and Wirral Gerard Majella Courthouse Boundary Street Liverpool Merseyside LS 2QD py Wy Volad 9, veh January 2020 Thank you for your correspondence of 24 June 2019, received by the Department of Health and Social Care on 27 August 2019, about the death of Mr Lewis James Doyle. I am replying as Minister with responsibility for patient safety and I am grateful for the additional time in which to do so. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Doyle’s death and I extend my deepest sympathies to his family and loved ones. I have noted the concerns in your report about ineffective communication between Mr Doyle’s medical practitioners and your recommendation that all medical attendants involved in a patient’s care should be sent discharge letters to ensure that they are aware of changes to that patient’s medication. I am aware that NHS England and NHS Improvement has advised you in its response of the requirements under the NHS Standard Contract 2019-20! for providers of care to share information on the discharge of patients, or transfer of their care, and that supporting guidance” recommends that information on medications should include those that have been stopped and the reasons why. Eats Carey 1-23. L.19.pdf More generally, clinicians have a duty to share information about their patients as they consider appropriate. Section 251B of the Health and Social Care Act 2012*4 places a duty on health and social care providers to share information about an individual with other health and care providers where it is likely to facilitate the care provided to the individual and is in their best interests. In addition, health professionals owe a duty of care to those they treat and this includes ensuring that information about their direct care is shared appropriately with other health and care professionals. The General Medical Council (GMC) regulates doctors in the UK. The GMC’s guidance, Good Medical Practice’, sets out the standards that doctors should meet in order to practice in the UK. This includes sharing ‘relevant information with colleagues involved in your patients’ care within and outside the team’. \n addition, the GMC’s ethical guidance on Leadership and Management’, says that ‘/r is essential for good and safe patient care that doctors work effectively with colleagues from other health and social care disciplines, both within and between teams and organisations’. I am advised that these legal and professional duties provide a clear framework for the effective sharing of information to support the care and treatment of patients, enabling medical professionals to make decisions on a case by case basis about the information that should be shared. I expect the local NHS to consider carefully the care provided to Mr Doyle and to take action where necessary to implement any learnings. While we do not believe that imposing further requirements to share data are necessary, the Government is committed to supporting the work of the Medicine Safety Improvement Programme’, led by NHS England and NHS Improvement, which aims to increase safety across the medication pathway, including in areas such as regular medication reviews and safe patient discharge. ” https://improvement.nhs.uk/resources/national-medicines-safety-programme! The Medicine Safety Improvement Programme will bring together a variety of projects to support medicine safety, from engaging patients as their own safety advocates, through to improvements to technology, to enabling the workforce to operate safely with strong systems and practices, to prevent harm. I am aware that NHS England and NHS Improvement has provided more detail in its reply to you on the work that is taking place to support the NHS with better technology to improve access to, and sharing of, clinical information. I hope this response is helpful. YY Nodes . NADINE DORRIES
INHS National Medical Director Skipton House Mr Andre Rebello : 80 London Road Senior Coroner for. Liverpool and _ SE1 6LH Wirral Gerard Majella Courthouse Boundary Street Liverpool L5 2QD -DEC 2019 18" December 2019 Dear Mr Rebello, Re: Regulation 28 Report to Prevent Future Deaths — Lewis James DOYLE Thank you for your Regulation 28 Report (hereinafter the ‘report’) dated 24 June 2019 concerning the death of Mr Lewis James Doyle on 8 January 2019. Firstly, | would like to express my condolences to Mr Doyle’s family. | note you directed identical Regulation 28 letters to NHSE and to NHSI. NHS E&l are jointly operating and this reply has been prepared and sent on behalf of both organisations. Your recent inquest into the death of Mr Doyle concluded that he died as a result of Organising Pneumonia due to traumatic injuries to his feet (with distal amputations), severe coronary artery disease and metastatic carcinoma of the prostate. Following the inquest, you have now raised concerns in the report for the consideration of NHS England regarding specifically the communication and information systems between healthcare providers in primary, secondary and tertiary care with regard to suspended or stopped medication. In the particular circumstances of Mr Doyle’s death this related to the stopping of Lithium in connection with his cardiac health. You suggest that there may be an opportunity to ensure all healthcare providers involved with a patient are included in any discharge information with regard to such decisions to suspend or stop medication. We know from the evidence and National Reporting and Learning Service (NRLS) that the transition of care is a high-risk situation. This is reiterated in the World Health Organisation (\WHO’)medication without harm challenge priority (https://apps.who. intiris/bitstream/handle/10665/325453/WHO-UHC-SDS-2019.9- eng.pdf?ua=1 ). ; | can confirm that the UK is responding to this challenge from the WHO through the National Medication Safety Programme being jointly run by the Department of Health and Social Care (DHSC) and NHS England and Improvement (NHSE/I). This NHS England and NHS Improvement mm Ys programme includes objectives on systems and practices that, amongst other things, covers the following points relevant to this case: e The accelerated roll-out of hospital e-prescribing and medicines administration systems e New systems linking prescribing data in primary care to hospital admissions e The development of a prioritised and comprehensive suite of metrics Whilst discharge summaries remain the responsibility of individual trusts, the NHS standard contract expects the transfer of information within 24 hours of discharge usually from provider to GP. The Discharge information should contain a full and accurate summary record of medications (both prescribed and non-prescribed) including any that were discontinued and any reasons for this — in line with . recommendations from The Academy of Medical Royal Colleges (AoMRC) and the Professional Record Standards Body (PRSB).1 The use of Dictionary of medicines and Devices (dm+d), (a dictionary of descriptions and codes for medicines and devices in use across the NHS), compliant Electronic Prescribing and Medicines Administration (EPMA) systems makes the process of sending and receiving medicines related information between organisations and health professionals easier and more accurate. It is recognised that this would improve patient safety and hence there is now national funding to support its roll out. | can confirm that NHS E/I provided funding for an additional 25 Trusts to have EPMA in this last week. The information standards for digital transfer of care do include changes to medicines albeit optional at present. These will be used for the basis for transfer of care in the future (PRSB standards https://theprsb.org/standards/edischargesummary/) As well as the funding for the EPMA roll out nationally there is support for Trusts regarding transfer of care around medicines from the Academic Health Science Networks (AHSNs). AHSNs are supporting the implementation of systems to facilitate - improved communication about medicines between healthcare sectors in line with evidence to show what works. This is designed to improve communication between hospital, community and primary care pharmacists including around discharge. The work is being led by Wessex AHSN on behalf of the AHSN network and uses technology and proven audit tools to facilitate this transfer. NHS E/lis closely involved in this work. In the North West Region, Share2Care (S2C) is a programme of work that stretches across the North West Coast of England Covering the organisations of Lancashire and South Cumbria Integrated Care Systems (ICS) and Cheshire and Merseyside STP (Sustainable Transformation Programme). The programme is a_ nationally funded digital and transformational programme that is part of the national Local Health and Care Record (LHCR) programme. S2C is classed as a wave 2 LHCR with several ICS/STPs already 2 years into the programme. S2C is an evolving programme in its 1st full year of deployment. In the Cheshire and Merseyside health ‘The Professional Record Standards Body (PRSB) provides professional and patient endorsed and evidence based clinical record standards which include discharge summary standards. The Academy of Medical Royal Colleges (AoMRC) “Standards for the Clinical Structure and Content of Patient Records’, published in 2013, were adopted by the PRSB, since it was established in 2013. This standard defines the headings, with descriptions, for electronic:records based on a number of specified use cases (admission, referral, discharge, outpatient letter, and handover). NHS England and NHS Improvement en care organisations are being connected to the sharing platform in stages. This is an iterative process that will see the clinical and eventually social care data available to view increasing. Currently the ability to share discharge summaries and:clinic letters is in place across the organisations that have been connected to date. The programme will also include a link to Lancashire &South Cumbria that will enable sharing of records across borders. North West Ambulance Service (NWAS) is also working with the programme to enable them to connect to the sharing platform. The programme is due to technically complete by March 2021; the improvement in the richness of data will also continue to develop beyond programme life cycle. Thank you for bringing this important patient safety issue to my attention and, please do not hesitate to contact me should you need any further information. _ Yours sincerely, >| ; sic = — NHS England and NHS Improvement’ NHS England and NHS Improvement ——— eS e——eE————EE
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