Prevention of Future Deaths reports · 2019

Muhammed Haleem

Regulation 28 report to prevent future deaths, reference 2019-0316, written 24 Sep 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report24 Sep 2019
Reference2019-0316
DeceasedMuhammed Haleem
CoronerCatherine McKenna
Coroner areaManchester North
CategoryEmergency services related deaths (2019 onwards) · Hospital Death (Clinical Procedures and medical management) related deaths
Organisation namedPennine Care NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1}

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. North West Ambulance Service (NWAS)

2. Pennine Care NHS Foundation Trust

CORONER

lam Catherine McKenna, Area Coroner for the Coroner area of Manchester North

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013

3 INVESTIGATION AND INQUEST

| On 21* May 2019, an investigation was commenced into the death of Muhammed Saif Abdul
| Haleem (dob: 12 November 2005). The investigation concluded at the end of the inquest on 24
September 2019.

The inquest determined that the medical cause of death was 1a) Unascertained. The conclusion
was Natural Causes.

4 CIRCUMSTANCES OF DEATH

Muhammed was 13 years old at the time of his death and had been born with a severe, life-limiting
neurological condition. He had congenital muscular dystrophy secondary to a gene mutation and
severe learning disability. He was non-verbal and could not mobilise by himself. He had a
permanent tracheostomy fitted in November 2011 and was fed via a Percutaneous Endoscopic
Gastrostomy.

In October 2011, when Muhammed was 6 years old, he had suffered an acute episode of severe
pneumonia and received intensive care at Royal Manchester Children’s Hospital. He had been
discharged from hospital on 14 November 2011 and those responsible for his care were of the
opinion that his death was imminent. A DNA-CPR document dated 11 November 2011 was
forwarded to his GP and NWAS.

Following this acute episode, Muhammed’s condition stabilised and after 2012, he had no further
in-patient admissions. He was cared for at home and attended Special Schools. He was under the
care of the Community Paediatric Team and in the last six months of his life had been seen by
specialists in nephrology, orthopaedics and respiratory medicine at the Children’s Hospital. His
condition was regarded as stable. Those involved in his care were unaware of the existence of the
2011 DNA-CPR document and | heard evidence from a Consultant Paediatrician that a DNA-CPR
at this time was ‘totally inappropriate.’

Muhammed had attended school the week before his death and | heard evidence from a School
Nurse who had seen him on Tuesday 4" December that he was ‘really well’. On Saturday 8"
December, Muhammed had woken in the early hours which was not unusual for him. He went to
sleep at about 10am and was checked by his mother at 11am. When his mother tried to rouse him
for his feed shortly after 12 noon, she discovered that he was unresponsive. NWAS was called at
12:18 hours and when the first paramedic arrived at 12:24 hours, Muhammed was in asystole and

there was no respiratory effort. The paramedic attempted resuscitation and was joined by further

crews who continued with resuscitation. Despite those efforts, Muhammed remained in asystole
throughout and resuscitation was terminated at 12:40 hours.

During the resuscitation, the paramedics had sought advice from the NWAS Clinical Support Hub
who advised that a pre-written warning was in place that resuscitation would not be in
Muhammed’s best interests. The pre-written warning on the NWAS system was undated but had
been taken from the DNA-CPR document dated 11 November 2011.

| found on the evidence that Muhammed’s condition at the time the paramedics attended on him
and the lack of response to resuscitation efforts meant that he would not have responded to further
resuscitative efforts, had they been continued.

Muhammed was transferred to the Royal Oldham Hospital where his death was certified at 14:40
hours on 8" December 2018.

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.

The MATTERS OF CONCERN are as follows:-

That information held on the NWAS system for the purpose of providing immediate guidance to
paramedics was 7 years out-of-date and was not known to or supported by the clinicians involved
in this child’s care at the time of his death. Whilst | accept the evidence that paramedics will make
a clinical decision based on the patient’s presentation at the time, the fact that they sought advice
around the existence of a DNA-CPR indicates that it is a relevant factor in their decision-making

The evidence was that the number of children living in the community with DNA-CPRs in place is
small and there should be communication between the community paediatric teams and
emergency services of any DNA-CPRs or Advance Care Plans that are in existence and are
current.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe each of you
respectively 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 20
November 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

namely:-
EEE Nuharmed's mother)
eo Medical Practice

Forget Me Not Hospice

| have also sent a copy of this report to Royal Manchester Childrens Hospital who may find it of
interest.

lam 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 from. He may ,
send a copy of this report to any person who he believes may find it usefulor 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.

Responses

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.

Response from North West Ambulance Service NHS Trust (PDF)
Our services: 
Emergency and urgent care  
Non-emergency patient transport  
NHS 111 

HM Area Coroner McKenna 
H M Coroner’s Court 
The Phoenix Centre 
L/CPL Stephen Shaw MC Way 
Rochdale  
OL10 1LR 

16 December 2019 

Dear HM Area Coroner McKenna 

Headquarters 
Ladybridge Hall 
399 Chorley New Road 
Heaton, Bolton 
BL1 5DD 

Tel:  01204 498400 

www.nwas.nhs.uk 

INQUEST TOUCHING UPON THE DEATH OF MUHAMMED SAIF ABDUL HALEEM 

I  write  further  to  the  Regulation  28  Report  which  you  issued  against  the  Trust  on  27 
September  2019,  following  the  conclusion  of  the  Inquest  touching  upon  the  death  of 
Muhammed Saif Abdul Haleem. 

I  understand  that  a  copy  of  this  response  will  be  shared  with  Muhammed’s  family  and,  on 
behalf of North West Ambulance Service, I wish to express my sincere condolences for their 
loss. 

Concern Raised 

You  raised  a  concern  that  the  information  held  on  the  NWAS  system  for  the  purpose  of 
providing immediate guidance to paramedics was 7 years out of date and was not known to 
or  supported  by  the  clinicians  involved  in  Muhammed’s  care  at  the  time  of  his  death.  You 
stated that the evidence was that the number of children living in the community with DNA-
CPR’s is small and there should be communication between the community paediatric teams 
and  emergency  services  of  any  DNA-CPR’s  or  Advance  Care  Plans  that  are  in  existence 
and are current. 

Notification of a DNA-CPR 

When  a clinical  decision  is  made  that  it  would  not  be  in  the best  interests  of the  patient to 
resuscitate and a DNA-CPR is put in place, NWAS receive a notification, primarily from the 
patient’s  GP  but  also  from  hospitals,  through  either  ERISS  (Electronic  Referral  information 
Sharing System) or an Addressbase or NHS.net email account. A DNA-CPR marker would 
only  be  placed  on  the  NWAS  system  against  the  patient’s  address  if  a  notification  was 
received from a healthcare professional or member of staff in a healthcare setting. 

A notification of a DNA-CPR via ERISS generally comes from a GP practice who will notify 
NWAS that a patient has been issued with a DNA-CPR and a marker is applied against the 

Headquarters: Ladybridge Hall, 399 Chorley New Road, Bolton, BL1 5DD 

Chairman:  Peter White 

Interim Chief Executive: Daren Mochrie 

 
 
 
 
 
 
          
 
        
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 patient’s  address.  Within  the  notification  the  GP  will  also  specify  a  review  date  which  is 
entered into the Trust gazetteer system. An automatic email from ERISS would then be sent 
to whoever created the notification 10 days before the expiration date and the GP practice 
should inform NWAS that the DNA-CPR marker is to be extended or removed.  

A notification of a DNA-CPR via Addressbase or NHS.net generally comes from a hospital or 
other  healthcare  setting  who  will notify  NWAS  that  a  patient  has  been  issued  with  a  DNA-
CPR  and  a  marker  is  applied  against  the  patient’s  address.  A  scanned  copy  of  the  DNA-
CPR may also be provided, which would be archived.  

It is important to make the distinction between a DNA-CPR marker and a DNA-CPR. A DNA-
CPR marker  is  an  advisory  notice  of  the  potential  existence  of  a  DNA-CPR for responding 
clinicians to look to locate a DNA-CPR on scene.  A DNA-CPR marker would not, of  itself, 
influence patient care but assists decision making. It does not mean that the Trust definitely 
will not resuscitate but is simply an indication of the patient’s likely outcome and what is best 
for their clinical needs. At no point would a DNACPR mentioned on a call be the only source 
of information for the decision to resuscitate.  

Review of a DNA-CPR 

The responsibility of review of a DNA-CPR remains with the patient’s referring clinician. If a 
DNACPR  is  revoked,  in  the  same  way  as  the  agreement  is  communicated,  NWAS  would 
expect the GP practice to communicate the change. If this does not happen, the DNA-CPR 
marker on the Trust system that remains in place is a warning of the potential existence of a 
DNA-CPR,  which  directs  the  clinician  to  look  for  a  paper  copy  of  the  DNA-CPR  when  on 
scene.  NWAS policy stipulates the commencement of resuscitation until information can be 
confirmed. NWAS  should  also  receive  requests  from  GP  practices  to  remove  a  DNA-CPR 
marker when a patient has passed away. 

Action being taken 

It is accepted that the NWAS needs to develop and implement a system which ensures that 
the NWAS is aware where DNA-CPR markers are out of date and/or require a review. The 
solution, however, is not a simple one. Consideration has been given to the block deletion of 
all  DNA-CPR  markers  which  are  over  12  months  old,  however  this  will  require  careful 
consideration of the impact this may have on the wider health system and also, appropriate 
opportunity for the Trust to communicate with GPs and the like about the proposed action. 

Your  Regulation  28  report  has  prompted  much  investigation  and  discussion  both  internally 
and  with  the  Trust  commissioners  about  not  only  DNA-CPR  markers  but  other  markers 
which are maintained on the Trust’s system.  

The  Trust’s  EOC  Governance  Group  have  been  tasked  with  reviewing  the  position  and 
making recommendations and we will provide you with an update as to progress within the 
next 3 months.    

- 2 - 

 
 
 
 
 
 
 
 
 
 I am sorry that you felt that there was cause to issue a Regulation 28 report and I hope that I 
have addressed you concerns by this response. If you require any additional information at 
this stage, please contact the NWAS Legal Services team. 

Yours sincerely, 

DAREN MOCHRIE QAM, MBA, Dip IMC RCSEd, MCPara 
Chief Executive 

- 3 -
Response from Pennine Care NHS Trust (PDF)
NHS}

Pennine Care
NHS Foundation Trust

: Corporate Services
Pennine Care Trust Headquarters
225 Old Street

Ashton under Lyne

Lancashire

OL6 7SR

20 November, 2019

Strictly Private and Confidential
Catherine McKenna Telephone: 0161 716 3000
HM Area Coroner

H M Coroner's Office Our Ref:_CP/djw
The Phoenix Centre — |
L Cpl Stephen Shaw MC Way

Heywood
OL10 1LR

Dear Ms McKenna
Re: Muhammed Haleem — DOD 08.12.18

| write following the inquest of Muhammed Haleem. The concerns you raised after
hearing all the evidence have been brought to my attention and | have subsequently
reviewed the Regulation 28 letter issued to Pennine Care NHS Foundation Trust.

The actions the Trust will take to address these concerns are as follows:

That information held on the NWAS system for the purpose of providing
immediate guidance to paramedics was 7 years out of date and was not known
to or supported by clinicians involved in this child's care at the time of his
death. Whilst | accept the evidence that paramedics will make a clinical
decision based on the patient’s presentation at the time, the fact that they
sought advice around the existence of a DNA-CPR indicates that it is a
relevant factor in their decision making.

The evidence was that the number of children living in the. community with
DNA-CPR’s in place is small and there should be communication between the
community paediatric teams and emergency services of any DNA-CPR's or
Advance Care Plans that are in existence and are current.

| can confirm that alerts have now been placed on the NWAS system for all children
who have current advance care plans (ACP) - these alerts will be reviewed if any
changes are made or as a minimum once per year when the ACP is reviewed. In
addition, we will review archived paper notes/records for any children with palliative
care needs known to the Children's Community Nursing Team (CCNT) on 15/11/49
to ensure that any ACP's that may have commenced before the electronic system
was set up are included.

(E23 disability
Trust Headquarters: 225 Old Street, Ashton-under-Lyne, Lancashire OL6 7SR. Tel: 0161 716 3000 @ confident
Visit us at www.penninecare.nhs.uk COMMITTED

We have also communicated with the Lead Nurse at the Royal Oldham Hospital
Children’s A&E department and forwarded a list of the children known to CCNT who
have ACP's to enable them to set up their own alert system. We have also
communicated with the Oldham Children's unit and O&A to replicate the same
system.

| hope that the information we have provided in terms of the actions taken offers
assurance to you.

Please do not hesitate to contact me should you require any further information.

Yours sincerely

Clare Parker
Executive Director of Nursing, Healthcare Professionals & Quality Governance

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