Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0111, written 16 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Apr 2021 |
|---|---|
| Reference | 2021-0111 |
| Deceased | Yusuf Seyit |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Lewisham and Greenwich NHS Trust |
| 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 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
Medical Director, University Hospital Lewisham,
Medical Director’s Office, Lewisham High Street, London SE13 6LH
1 CORONER
I am Andrew Harris, Senior Coroner, London Inner South jurisdiction
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INQUEST
I opened an inquest into the death of Mr Yusuf Seyit, (
who died on 3rd July 2019 aged 72 years on 12th September 2019. The delay in
holding the inquest was ascribed to the impact of the Covid pandemic.
and
),
The medical cause of death was: 1a Septicaemia 1b Urinary Tract Infection II
Immunoglobulin G4 disease, Myelodysplastic syndrome, Diabetes Mellitus. The
narrative conclusion was natural causes was contributed to by a delay in
administering antibiotics in septic shock.
4 CIRCUMSTANCES OF THE DEATH
Mr Seyit suffered from multiple diseases which immunosuppressed his response to
infection and had been in hospital since January. The family reported pain on
passing urine on 30th June. He had an indwelling catheter and a urine infection
was suspected on 1st July, when he had suprapubic tenderness as well as signs
suggestive of a chest infection. The urine result was reported at 17.50 on 2nd July
as highly resistant E coli, sensitive to Amikacin. At this time he was stable but
there was an indicator of infection – the slightly elevated CRP of 23. He acutely
deteriorated at 05.00 with septic shock and a medical review concluded at 06.25.
He was prescribed three antibiotics (he had a chest infection as well) including
Amikacin. It is not known when in the morning Amikacin was administered. He
died at 20.00
5 CORONER’S CONCERNS
The MATTERS OF CONCERN are as follows. –
1. He was known to be at high risk of fatal infection and had developed
symptoms 2 days before death and definitive proof of infection by the late
afternoon of 2nd July, but it was not clear whether there was a plan for
antibiotic intervention and no treatment was begun that day.
2. When in septic shock in the early hours of 3rd, three antibiotics were
prescribed and our initial death report indicated treatment had begun
before he died. But the medical records available to the inquest did not
confirm when Amikacin was actually administered. Evidence of a
consultant physician was that it needed to be within an hour.
6 ACTION SHOULD BE TAKEN
The coroner draws attention of The Trust, with the family’s support, to the need
to ensure that appropriate antibiotics for septic shock are available within the hour
after prescription at any time of day or night. It may be that this facility is in
operation but the evidence not adduced. In any event the Trust may wish to assure
the public of the processes of securing administration of life-saving medication for
sepsis at all times.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by Friday, 11th June 2021. I, the coroner, may extend the period.
If you require any further information or assistance about the case, please contact
the case officer,
8 COPIES and PUBLICATION
I have sent a copy of my report to the following Interested Persons:
inquest coordinator, UHL
I am also sending this report to the following, who have an interest and may be in
a position to offer advice on mitigating such tragedies:
Royal College of Physicians.
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
[DATE] [SIGNED BY CORONER]
16th April 2021
Andrew Harris, Senior 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.
NHS Trust University Hospital Lewisnam Lewisham High Street London SE13 6LH a Mag HMSC Andrew Harris please ec tw [Pe Southwark Coroners Court 1 Tennis Street Ad / G London SE11YD 40 June 2021 Cerne! Q Dear Bf Harris REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Re: Mr YUSUF SEYIT | am writing in response to your report dated 16 April 2021, concerning the care provided to Mr Seyit. Your report highlighted two matters of concerns which are listed below. 1. Mr Seyit was known to be at high risk of fatal infection and had developed symptoms two days before death and definitive proof of infection by the late afternoon of 2" July 2020, but it was not clear whether there was a plan for antibiotic intervention and no treatment was commenced that day. 2. When in septic shock in the early hours of 3 July 2020, three antibiotics were prescribed, and the Trust initial death report indicated treatment had commenced before he died. However, the medical records available to the inquest did not confirm when Amikacin was actually administered. Evidence provided by a consultant physician confirmed that it needed to be within an hour. As a result, the Trust is required to ensure the appropriate antibiotics for septic shock are prescribed and administered within the hour at all times irrespective of the time of day. Following receipt of this report, the Trust completed an internal review of the incident and confirmed that Mr Seyit was prescribed antibiotics at 07:00hrs, which were administered at 07:49hrs which was within the hour. We acknowledge and apologise that The Trust did not provide the appropriate evidence required during the inquest. \. High quality care for every patient P every day However, the Trust has taken the opportunity to review its current practices around sepsis and take the following steps: _ The Trust and Division have re-audited sepsis performance on all clinical wards against the Sepsis 6 Bundle Standards and actions have been taken to improve gaps in practice. This will be monitored through our internal governance processes. _ The Trust will ensure that all wards are adequately stocked with the paper version of the Sepsis Assessment Bundle, and all clinical staff have been reminded that prescribed critical medications are to be administered to patients within an hour of being prescribed by a doctor. This is discussed at Ward Safety huddles and local team meetings. . The Trust is prioritising the implementation of an electronic (iCare) Sepsis Bundle. This was originally scheduled for 2022. Discussion have taken place with the Trust IT department and there are plans for this to be completed later this year. This will be monitored via Divisional Governance processes and assurance given via the Trust Quality and Safety Committee. | would like to assure you that the Trust has taken the concerns raised seriously and learning from this incident has been shared at the Trust Mortality Review Committee, Divisional Mortality and Morbidity and the Junior Doctors review meetings. Should you have any further questions regarding any of the information provided in this letter or require any furtherinformation please do not hesitate to contact me. Yours sincerely Dr Medical Director Lewisham and Greenwich NHS Trust ‘, High quality care for every patient F every day
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