Prevention of Future Deaths reports · 2019
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 report | 24 Sep 2019 |
|---|---|
| Reference | 2019-0316 |
| Deceased | Muhammed Haleem |
| Coroner | Catherine McKenna |
| Coroner area | Manchester North |
| Category | Emergency services related deaths (2019 onwards) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Pennine Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
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.
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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 -
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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