Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0073, written 19 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Feb 2021 |
|---|---|
| Reference | 2021-0073 |
| Deceased | Lisa Grant |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Black Country Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Health and Social Care 2. Chief Executive, Black Country Partnership NHS Foundation Trust 3. Care Quality Commission (for information only). 1 CORONER I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country. 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On the 12 August 2019, I commenced an investigation into the death of Ms Lisa Grant. The investigation concluded at the end of the inquest on the 15 December 2020. The conclusion of the inquest was a short form conclusion of natural causes. The cause of death was: 1a Bilateral Pulmonary Embolism 1b Deep Vein Thrombosis 4 CIRCUMSTANCES OF THE DEATH i) Ms Grant was admitted to Hallam Street Hospital on the 29 July 2019 under s3 MHA. She had been diagnosed with Bipolar Affective Disorder and had numerous previous admissions. ii) In terms of her medical history she had insulin dependent diabetes, iron deficiency anaemia, sickle cell trait and Raynaud's disease. Her medication included risperidone which is an antipsychotic or neuroleptic. iii) Ms Grant had gained weight and was obese. One of the common side effects of risperidone medication included eating more and therefore weight risk of developing venous is gain. Another thromboembolism (VTE). factor rare risk the iv) On the 1 August 2019 she collapsed on the ward and became unresponsive. Despite resuscitation attempts by staff and paramedics she sadly died a short time later at Sandwell Hospital. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In 1 [IL1: PROTECT] 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. – 1. Evidence emerged during the inquest that both the consulting Psychiatrist and the Hospital’s Manager said that Ms Grant was assessed upon admission to hospital in accordance with the national guidelines for the assessment for Deep vein thrombosis (DVT). As per the guidance criteria checklist, the clinician considered that there was no significant reduction in mobility, and therefore no further treatment or assessment for this condition was required. 2. Miss Grant had a significantly increased risk of DVT due to the effects of obesity and inactivity. In addition, there was a rare but recognised side effect of Risperidone. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 1. You may wish to consider reviewing and revising the DVT national guidance checklist for long term patients with increased risk factors of obesity, immobility, and risperidone medication. 2. Specifically, when the sole criterion of immobility is met then there is no requirement for further examination or assessment by the clinician should be urgently reviewed. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19 April 2021. 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 Chief Coroner and to the following Interested Persons; Family. 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. 9 19 February 2021 Mr Zafar Siddique Senior Coroner Black Country Area 2 [IL1: PROTECT]
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.
Mr Siddique Senior Coroner Black Country Coroner’s Service Coroners Court, Jack Judge House, Halesowen Street, Oldbury, B69 2AJ Dear Mr Siddique Trust Headquarters Delta Point Greets Green Road West Bromwich B70 9PL 11 January 2021 On 15 December 2020, at the conclusion of the inquest into the death of Lisa Grant, you asked me to discuss with the Trust (and respond within 28 days) as to whether any alternatives to an evac chair could/should be placed at Hallam Street Hospital e.g. a scoop. Please see my response below. Background Lisa was on the first floor of Hallam Street Hospital when she collapsed and required extrication down the stairs to the ambulance. There is no lift available. In this incident, as Lisa was in cardiac arrest, the options available to safely move her whilst minimising interruptions to chest compressions was on a scoop or stretcher. As the ambulance crew needed to move Lisa down a flight of stairs, a scoop would have offered the safest level of transportation as it secures the patient in a fixed position more so than a stretcher and as the patient lies flat, it minimises the interruptions to chest compressions. Stretchers are primarily used for transport over level ground and are physically heavier than a scoop to lift; therefore, not practical to be manually handled by crew up or down stairs. On the CCTV footage of the incident, the ambulance crew can be seen placing the scoop onto the stretcher, which was at the bottom of the stairs, to transport Lisa to the awaiting ambulance. Evac chairs were installed at Hallam Street Hospital after Lisa’s death to enable patients to be brought downstairs in the event they cannot walk. However, an evac chair would not have been an option to use to move Lisa, as it would not have been possible to maintain effective chest compressions. You enquired whether an alternative, e.g. a scoop, should be installed at Hallam Street Hospital. Response This question has now been raised with the Trust Resus Committee and advice and guidance has also been sought from third sector emergency services and resuscitation services. The Trust responds that once ambulance crews attend any emergency, it is their responsibility to risk assess the environment, situation and clinical presentation of the patient and how best to move an individual, if conveyance to the ambulance is necessary. As a mental health trust, our staff are trained in initial life support and CPR to maintain life while emergency services are on their way and the Trust feel that our staff are not experts in moving patients during trauma. Manual handling requirements and skills for ambulance crews are significantly different to that of staff working within a hospital or clinic setting and ambulance crews have a responsibility to regularly check and maintain any equipment they may be required to use when responding to an emergency call. As such, the Trust would anticipate that when undertaking manual handling interventions, which significantly increases the risk to the individual, the ambulance service would only use equipment they know is fit for purpose. The Trust would recommend leaving the extrication phase to the ambulance service. The ambulance service can call upon Hazardous Area Response Teams and/or the Technical Rescue Teams from the fire service if there is a complex extrication. The ambulance service also has bariatric lifting capability, which they can draw upon. Conclusion The Trust recognises that the evac chair would not have been suitable in this incident or similar incidents and the Trust has considered whether to install a stretcher or a scoop. However, the Trust have concluded that the ambulance service must be responsible for the extrication of a patient and should be responsible for providing (and maintaining) their own extrication equipment. The Trust recognise that staff must ensure that when calling 999 for an ambulance they confirm if the patient is bariatric, in a confined space or on the first floor. This will be included in future training and an email will go out to all staff to ensure awareness. This will help to ensure the ambulance service responds appropriately and brings the correct extrication equipment. If you have any further concerns or require further clarity on any on the points raised, please do not hesitate to come back to me and l will happily provide you with a response. Yours sincerely General Manager, Sandwell Mental Health Services Black Country Healthcare NHS Foundation Trust.
From Nadine Dorries MP Minister of State for Patient Safety, Suicide Prevention and Mental Health 39 Victoria Street London SW1H 0EU 21 June 2021. Mr Zafar Siddique HM Senior Coroner, Black Country Black Country Coroner's Court Jack Judge House Halesowen Street Oldbury West Midlands B69 2AJ Dear Mr Siddique, Thank you for your correspondence of 18 March 2021 and the Prevention of Future Deaths report relating to the death of Lisa Grant. I am responding as Minister responsible for mental health services and I am grateful for the additional time in which to do so. Firstly, I would like to say how sorry I was to read the circumstances of Ms Grant’s death and I would like to take this opportunity to offer my sincere condolences to the family, friends and loved ones of Ms Grant. It is important that we take the learning from what happened to Ms Grant to improve the safety and quality of NHS care. I have noted carefully your concerns about the increased risks of deep vein thrombosis (DVT) to patients with a severe mental illness who are prescribed the antipsychotic drug, risperidone. In preparing this response, my officials have made enquiries with NHS England and NHS Improvement (NHSE/I) and the National Institute for Health and Care Excellence (NICE). As your report identifies, venous thromboembolism (VTE) is a known side-effect of risperidone and other anti-psychotic medicines. This is noted in the Summary of Product Characteristics and the British National Formulary and prescribers are expected to take known side-effects into account when making prescribing decisions with their patients. NICE guidance (Venous thromboembolism in over 16s: reducing the risk of hospital- acquired deep vein thrombosis or pulmonary embolism, NG891) is clear that all acute psychiatric patients should be assessed to identify their risk of VTE and bleeding: 1 venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism • As soon as possible after admission to hospital, by the time of the first consultant review, or if their clinical condition changes; and, • Using a tool published by a national UK body, professional network or peer- reviewed journal. The Guideline references a tool commonly used in the NHS for hospital patients: the Department of Health risk assessment for VTE (see recommendation 1.9.1). NICE notes in the Guideline that the tool has not been validated or tested against other tools to evaluate its diagnostic accuracy or effectiveness at correctly identifying people at risk of VTE. The NICE guideline committee made a research recommendation in this area, reflecting the uncertainty in the evidence for one risk tool over another. You may wish to note that in May 2021, NICE updated the Guideline in response to an investigation report, Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke2, published by the Healthcare Safety Investigation Branch (HSIB). The update clarified that the role of the risk assessment tool is to aid the development of the treatment plan. The national tool acknowledges that the risk factors identified are not exhaustive, and clinicians may consider additional risks in individual patients and offer thromboprophylaxis as appropriate. I am advised by NICE that it will consider the use of specific tools for acute psychiatric patients at its next review of National Guideline 89. Due to the metabolic disturbance associated with anti-psychotic medication, such as risperidone, NICE recommends that patients prescribed these drugs are regularly monitored for side-effects with a comprehensive annual physical health assessment for patients with a severe mental illness (SMI), Ongoing care for adults with psychosis or schizophrenia. This health-check addresses the key drivers of reduced life expectancy in people with SMI, including cardiovascular disease and metabolic disorders. Where risks are identified, it is recommended that patients should be transferred to the relevant care pathway, for example, the diabetes pathway. More specifically, when anti-psychotics are initiated3, baseline measurements should be taken in secondary care with the patient remaining under the responsibility of the secondary care team for the first 12 months. Regular monitoring should then be completed in primary care. Meeting the physical health-needs of people with SMI is a key component of the new and integrated models of care. During 2021/22, the NHS is investing an additional £24 million to incentivise the completion of these checks in primary care via the Quality and Outcomes 2 Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke - Healthcare Safety Investigation Branch (hsib.org.uk) 3 Monitoring | Prescribing information | Psychosis and schizophrenia | CKS | NICE Framework (QOF). This will ensure that people with SMI are supported to access vital health-checks which will prevent and manage physical health conditions. In addition, 390,000 people with SMI are expected to access a comprehensive annual physical health-check and follow-up interventions by 2023/24, this is supported by significant government investment. Finally, I am pleased to note the learning that has been taken locally from the circumstances of the death of Ms Grant. My officials have been made aware of the following actions taken by the Black Country Healthcare NHS Foundation Trust • The need to evidence through documentation that patient risk has been considered and planned accurately; • That patient physical health care plans should be as comprehensive as possible. That care plans should provide guidance for the patient and their support network when a patient’s health deteriorates; • The need for more frequent refresher simulations to promote and improve life support skills training for staff; • Clinical documentation standard to be improved including the physical health monitoring, progress notes, and handover information. In addition, recommendations arising from the Trust’s investigation into the care and treatment provided to Ms Grant include having medical cover to attend emergencies at Hallam Street hospital; and Immediate Life Support algorithm to be followed during medical emergencies with delivery of timely interventions. I hope this information is helpful and explains the actions being taken to address the matters of concern. Thank you for bringing these matters to my attention. NADINE DORRIES
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