Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0446, written 20 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Dec 2019 |
|---|---|
| Reference | 2019-0446 |
| Deceased | Keith Hill |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| 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.
Regulation 28: Prevention of Future Deaths report
Keith HILL (died 27.06.19)
THIS REPORT IS BEING SENT TO:
1. Dr Alistair Chesser
Chief Medical Officer
Barts Health
Royal London Hospital
Whitechapel Road
London E1 1BB
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 3 July 2019, one of my assistant coroners, Sarah Bourke,
commenced an investigation into the death of Keith Hill aged 71 years.
The investigation concluded at the end of the inquest yesterday.
I made a determination at inquest that Keith Hill died from a combination
of natural causes and the complications of medical treatment.
I recorded a medical cause of death of:
1a general sepsis
1b obstructive ischaemic biliary stricture
2 ischaemic heart disease, diabetes and renal failure.
1
4
CIRCUMSTANCES OF THE DEATH
Mr Hill was admitted to the liver unit of the Royal London Hospital with a
working diagnosis of biliary sepsis. He had heart disease, diabetes and
kidney failure.
On 7 May 2019, he underwent endoscopic retrograde cholangio-
pancreatography (an ERCP). However, he remained very unwell. His
renal impairment deteriorated and he was put on haemodialysis. The
cause of the ongoing inflammation of his liver was unclear. He was
known to be at high risk for a liver biopsy, but it was considered there
was no alternative to this.
A transjugular biopsy was planned by the hepatologists because Mr Hill
had ascites, but the interventional radiologist conducting this decided
upon a percutaneous approach despite its higher risk of bleeding,
because improvement in the ascites made this feasible. The
percutaneous approach is more likely to yield a successful sample.
The biopsy was carried out on 24 May, but within a few hours Mr Hill had
developed a bleed from the biopsy site, and later that same day he had
to undergo a laparotomy to oversew the hole.
He later suffered bowel haemorrhage and was treated repeatedly for this.
Meanwhile, the biopsy had revealed intra hepatic biliary obstruction.
On 24 June, the microbiologists advised the antifungal agent micafungin.
The hepatologists considered this but were concerned it was too
hepatotoxic. In the event, Mr Hill deteriorated and on 25 June a
prescription for micafungin was written. However, the prescription was
never filled.
Mr Hill died on 27 June 2019. After his death, the results of his blood
cultures demonstrated that he did not have fungal sepsis, so the failure
to administer the micafungin had no impact in this instance. Of course
that might not be the case for another patient.
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.
The MATTERS OF CONCERN are as follows.
2
1. When the plan changed and the transjugular liver biopsy became
a percutaneous one, there was no communication between the
interventional radiologist and the hepatologists. Even if it had not
changed the plan, Mr Hill’s management would have benefited
from a robust discussion between the specialists in these two
fields, and an accurate record of the decision making.
2. Mr Hill’s medical records were at times inadequate. The
microbiologists thought that the junior hepatologists were making
a record and vice versa. In the event, neither did. Most
specifically, following the repeated advice of the microbiologists,
the decision to change the plan and to prescribe micafungin on 25
June was not documented, it was simply written up on the
prescription chart.
3. The junior pharmacist charged with dispensing the micafungin on
the evening of 25 June recognised its toxicity to the liver and could
not see from the medical record that Mr Hill’s liver function tests
and hepatitis had been taken into account in the prescription.
The last relevant entry in the medical record indicated that the
micafungin should be held off.
He sought senior guidance. However, there was no specialist
hepatology pharmacist on the list of available contacts.
Recognising he was outside his expertise, he contacted an
intensive care specialist pharmacist, the on call microbiologist and
the medical doctor looking after Mr Hill. However, no decision was
made regarding the micafungin and so it was simply not given.
A professor of hepatology was on call and knew Mr Hill’s situation
well, but he was not contacted by the ward doctor (or by the
microbiologist or a senior pharmacist).
Despite improvements to the availability of senior pharmacists on
call at the Royal London Hospital, concern remains about night
time care and proper scrutiny of prescriptions. Junior medical
staff do not appear to be sufficiently supported in this.
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.
7
YOUR RESPONSE
3
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 24 February 2020. 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
Professor
r, consultant hepatologist
, partner of Keith Hill
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
20.12.19
4
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.
Royal London Hospital Room 007 Floor 10 South Tower www.bartshealth.nhs.uk Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Ms Hassell I am writing in response to the Prevention of Future Deaths report regarding the death of Keith Hill at the Royal London Hospital on 27 June 2019. There are three matters of concern: When the plan changed and the transjugular liver biopsy became a percutaneous one, there was no communication between the interventional radiologist and the hepatologists. Even if it had not changed the plan, Mr Hill’s management would have benefited from a robust discussion between the specialists in these two fields, and an accurate record of the decision making. This case has led to a review of how decisions are discussed and documented between the treating team and the interventional radiology team. There are regular and documentated discussions in the MDT meeting between the medical teams and the interventional radiologists; in addition there are conversations between referring teams and the interventional radiologists if non-elective patients are being treated without having been through a formal MDTdiscussion. In this context it is agreed between all clinical teams that at the time of the procedure the interventional radiologists will decide as to how to proceed based on their clinical knowledge, experience and the clinical situation at that point. Further conversations with the referring team at this point and in this case would not have changed the procedure performed. However, if the planned procedure proves impossible, or by the time the patient arrives in the IR theatre the patient has had a significant change in condition, the radiologist would contact the referring team. All significant decisions should be documented in the patient record. The importance of this has been reinforced. Mr Hill’s medical records were at times inadequate. The microbiologists thought that the junior hepatologists were making a record and vice versa. In the event, neither did. Most specifically, following the repeated advice of the microbiologists, the decision to change the plan and to prescribe micafungin on 25 June was not documented, it was simply written up on the prescription chart. Note keeping has been reviewed by the consultant body and there has been agreement that the quality of note keeping must always meet the standards of best practice. There will be regular audits of note keeping at the monthly M&M meeting to drive and maintain improvement. The junior pharmacist charged with dispensing the micafungin on the evening of 25 June recognised its toxicity to the liver and could not see from the medical record that Mr Hill’s liver function tests and hepatitis had been taken into account in the prescription. The last relevant entry in the medical record indicated that the micafungin should be held off. He sought senior guidance. However, there was no specialist hepatology pharmacist on the list of available contacts. Recognising he was outside his expertise, he contacted an intensive care specialist pharmacist, the on call microbiologist and the medical doctor looking after Mr Hill. However, no decision was made regarding the micafungin and so it was simply not given. A professor of hepatology was on call and knew Mr Hill’s situation well, but he was not contacted by the ward doctor (or by the microbiologist or a senior pharmacist). Despite improvements to the availability of senior pharmacists on call at the Royal London Hospital, concern remains about night time care and proper scrutiny of prescriptions. Junior medical staff do not appear to be sufficiently supported in this. Following this case, the hepatology team have reiterated to the junior doctors on the team the availability of consultant support and have ensured that the switchboard contact details and ward 'white board' is up to-date. This will also be repeated during the induction training of new medical juniors and the consultants are stressing to their trainees the importance of escalation. Since October 2019, the Pharmacy Department has instituted a positive change in the out of hours clinical support provided to junior pharmacists on-call.There is now a published rota, where each evening there is an accountable senior pharmacist off-site who is available to discuss and provide advice and resolution for any complex patients or issues. This includes advising on the need for specialist clinical advice and escalating where necessary. This support ensures our junior pharmacists and patients benefit from expert senior clinical pharmacy advice out of hours as well as during the normal working day. Pharmacists have reported in their monthly meetings that they now feel very well supported and having a named point of contact out of hours provides much needed discussion and advice when necessary. Yours sincerely Consultant Anaesthetist Medical Director RLH Responsible Officer Barts Health
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