Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0047, written 28 Feb 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Feb 2020 |
|---|---|
| Reference | 2020-0047 |
| Deceased | Irene Whittingham |
| Coroner | Rachel Syed |
| Coroner area | Manchester (West) |
| Category | Alcohol, drug and medication related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Bolton NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: . Ms Jackie Bene, Chief Executive, The Royal Bolton Hospital, Minerva Road, Bolton. BL4 7HR . Mr Roy Blay, Chief Executive, WellSky, 1 Aurum Court, Sylvan Way, Southfield Business Park, Basildon, Essex, SS15 6TH . Mr Andy Thorburn, Chief Executive, EMIS, Aspinall House, Aspinall Close, Middlebrook, Horwich, BL6 6QQ CORONER I am Rachel Syed, HM Assistant Coroner for the Coroner Area of Manchester West. CORONER’S LEGAL POWERS T 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. INVESTIGATION and INQUEST On the 09 August 2019, I commenced an Investigation into the death of Irene Whittingham, born on the 24" November 1932. The Investigation concluded at the end of the Inquest on the 21 February 2019. The medical cause of death was: - 1a) Bilateral Hypostatic Pneumonia 1b) Multi Organ Failure ic) Hypercalcaemia due to Vitamin D Toxicity II) Hyperparathyroidism, Ischaemic Heart Disease and Nephrosclerosis The Inquest conclusion was Accident contributed to by Neg CIRCUMSTANCES OF THE DEATH The deceased died at The Royal Bolton Hospital on the 31st July 2019 from the toxic effects of a Vitamin D overdose. The deceased suffered from a number of medical illnesses, including liver and kidney disease, hyperparathyroidism with Vitamin D malabsorption, small vessel disease and hypertension for which she was receiving treatment for these conditions. On or around the 22nd March 2019, the deceased was admitted to hospital with seizures and it was clinically suspected that the cause was due to a cerebral event. Investigations also revealed low Vitamin D levels and advice was sought from a Specialist who recommended 20,000 international units of Vitamin D to be given twice a week for 3 months. In error, the discharge summary incorrectly recorded the Vitamin D to be given once a week. The ward pharmacist picked up the error but incorrectly amended the discharge summary for the medication to be given twice daily. No advice was given about monitoring the deceased's blood levels whilst she was being loaded on a high dose of Vitamin D which exceeded the national guidelines. The deceased was deemed fit for discharge on the 12th April 2019 and her prescription was dispensed in the community. On the 10th June 2019, the deceased was readmitted back to hospital and treated for acute kidney injury and Vitamin D toxicity. The deceased's condition did not improve and she died on the above date. 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: During the Inquest, evidence was heard that: - 1. Conflicting guidance is provided to treating clinicians as to when Vitamin D and Calcium blood level monitoring should be undertaken especially in patients who are given higher (loading) doses of Vitamin D, which exceeds the recommended national guidelines. The Consultant in Acute Adult Medicine gave evidence that he expected blood level monitoring to have taken place within 4 weeks of the loaded Vitamin D commencing, whereas the Endocrinologist, gave evidence that he expected blood level monitoring to take place around the 3 month period to ensure the course of medication had been completed. In any event, no advice or instructions were issued to the deceased GP, regarding any requirement to monitor the deceased blood levels whilst she was in the community and taking high levels of Vitamin D which exceeded national guidelines. . TI request that The Chief Executive of The Royal Bolton Hospital reviews: The guidance and practices being adopted by staff, in regard to when blood monitoring of the above types of patients should take place to ensure a consistent and safe approach is adopted. 3. The WellSky and EMIS Software, had a confusing user drop down menu option, which allowed the user to click on a twice daily dose despite the loaded dosage, exceeding national guidelines. . TIrequest that The Chief Executives of WellSky and EMIS Software company reviews: 5. The dropdown user options to ensure better system safety nets are put in place to prevent catastrophic prescribing errors occurring in the future ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that you 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 by 24™ April 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- 1. F Son of deceased 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. Dated 28" February 2020 b bd Rachel Syed HM Assistant Coroner
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.
Telephone: aE Please ask for: — Our Ref: Bolto n NHS Foundation Trust Bolton NHS Foundation Trust 23 April 2020 Minerva Road Farnworth BL4 OJR Mrs Rachel Syed HM Assistant Coroner Coronial Area of Manchester West Paderborn House, Civic Centre BOLTON BLi 1JW Dear Mrs Syed, Re: Irene Whittingham Re: Regulation 28 Report to Prevent Future Deaths | am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued following the Inquest touching the death of Irene Whittingham on 21 February 2020. May | take this opportunity to extend my sincere condolences to the family of Mrs Whittingham for their loss and appreciate this will be a difficult time for the family. | note that prior to the Inquest hearing, you were provided with a Serious Incident Review Report confirming that a number of actions in relation to the dispensing error had already been taken by the Trust. Following receipt of the Regulation 28 Report, the previous Chief Executive, Dr J Bene requested that the Chief Pharmacist and Deputy Medical Director review the matters detailed in your Report. | am now in a position to respond to your concerns as outlined in Section 5. Section 5 (1) | am very sorry to learn that during the course of establishing how Mrs Whittingham came about her death you heard evidence that there was a lack of clarity regarding the monitoring of Mrs Whittingham following the prescribing of a higher loading dose of the medication. In order to address the concern, the attached prescribing guideline has been developed by the Clinical Pharmacy Team with contributions by the specialist doctors. The guideline will standardise and support the safe prescribing and administration of colecaliferol in adult patients. With regards to the prescribing of colecalciferol to patients under the age of 18 the Trust has guidance already in place and use. www.boltonft.nhs.uk In addition to the actions already taken in the Serious Incident Report | hope that my response has provided you and the family with the assurance that the Trust has taken additional appropriate action to mitigate the risk of future deaths. Please do not hesitate to contact me in the event you require any further assistance. Yours sincerely, fare Cokan Fiona Noden Chief Executive cc: PY Chief Pharmacist
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