Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2021-0005, written 11 Dec 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Dec 2020 |
|---|---|
| Reference | 2021-0005 |
| Deceased | Shyama Rampadaruth |
| 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 Shyama Vadwatee RAMPADARUTH (died 17.04.20) THIS REPORT IS BEING SENT TO: 1. Medical Director Whipps Cross Hospital Whipps Cross Road Leytonstone London E11 1NR 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 2020, I commenced an investigation into the death of Shyama Rampadaruth, aged 86 years. The investigation concluded at the end of the inquest earlier today. I made a determination at inquest of death by natural causes. 4 CIRCUMSTANCES OF THE DEATH Ms Rampadaruth had a number of co-morbidities, including renal failure, diabetes, hypertension, heart failure, asthma and cervical spondylosis. When she attended Whipps Cross Hospital for her routine renal dialysis on 13 April 2020, she was found to have a raised temperature and so was moved to a separate waiting area and dialysed with other patients suspected of having contracted COVID19. 1 She was discharged home as usual, but deteriorated that night and was admitted as an emergency in the early hours of the following morning. COVID19 was diagnosed, she continued to deteriorate and died three days later. 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. When COVID19 was suspected at her routine dialysis appointment on 13 April, precautions were taken to separate Ms Rampadaruth from other patients to reduce the risk of transmission. She was re-allocated to the evening dialysis clinic with other potentially infectious patients, so that the unit could be thoroughly cleaned overnight to make it safer for patients at the next clinic the following day. However, this meant that Ms Rampadaruth had to wait for approximately six hours on a hard chair in a hospital waiting area. This is clearly sub optimal for the health of a frail, elderly lady with multiple co-morbidities. The patient transfer service is likely to have been busy, but Ms Rampadaruth and her husband lived nearby. Her niece, who was very involved with her care, works locally. A quick call to a family member would have resulted in immediate arrangements being made to collect Ms Rampadaruth, bring her home to sit in comfort with familiar company and her usual food and drink, and then to return her when hospital staff were ready to begin her dialysis. Her general well being could have been so enhanced by just a small change to administrative arrangements. 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 You are under a duty to respond to this report within 56 days of the date of this report, namely by 8 February 2020. I, the coroner, may extend the period. 2 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 , nephrologist, Whipps Cross Hospital , niece of Shyama Rampadaruth I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 DATE SIGNED BY SENIOR CORONER 11.12.20 3
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.
Private & Confidential
Ms Mary Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London
N1C 4PP
Dear Ms Hassell,
Trust Executive Office
Ground Floor
Pathology and Pharmacy Building
The Royal London Hospital
80 Newark Street
London E1 2ES
Telephone:
Chief Medical Officer
www.bartshealth.nhs.uk
RE: Regulation 28 Prevention of Future Deaths Report
I write in response to your Regulation 28: Report to Prevent Future Deaths, dated 11th
December 2020. Your concern was related to the environment Ms Shyama Vadwatee
Rampadaruth waited in on the 13th April 2020.
At the inquest you raised the concern that Ms Rampadaruth waited 6 hours on a hard chair in
the hospital waiting area rather than being allowed to go home while she waited for an evening
dialysis session.
This event took place during the first peak of Covid 19 in April 2020 and the steps taken that
day were an emergency measure. The team recognise that the lady’s experience of waiting for
her dialysis session would have been better in her own home rather than in the hospitals
waiting area.
I would like to assure you that since that day a significant number of actions have taken place
to improve the experience of patients attending dialysis. All dialysis patients are now swabbed
weekly so Covid cases are picked up on asymptomatic patients. This has allowed us to isolate
and cohort Covid positive patients in a more planned fashion than Ms Rampadaruth
experienced during the first wave and we have, so far, been able to keep all our covid positive
dialysis on a single site. Additionally the renal team now have access to portable dialysis
machines that were not available during the first surge in March and April 2020. This has given
the team more flexibility in arranging urgent isolated dialysis when needed.
The dialysis service runs at over 99% capacity and so a lack of reserve does make managing
dialysis safely through the pandemic extremely challenging. They are therefore actively
planning to increase capacity and are seeking the resources needed to enable this.
Finally the renal team recognise that vaccinating their vulnerable cohort of patients is likely to
be the best strategy to prevent future deaths among their vulnerable cohort of patients. They
have been strongly advocating for this and I am pleased to say we have started vaccinating
the dialysis patients when they attend for their sessions.
Thank you for bringing your concerns to my attention. I trust that you are assured that I have
taken them seriously. I am very happy to discuss or clarify any of the above points.
Yours sincerely
Chief Medical Officer
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