Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0246, written 16 Jul 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 Jul 2021 |
|---|---|
| Reference | 2021-0246 |
| Deceased | Brian Jackson |
| Coroner | David Lewis |
| Coroner area | Liverpool and Wirral |
| 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: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 National Institute for Health and Care Excellence (NICE) 2 Family of the Deceased (copy) 3 Chief Coroner (copy) 4 Liverpool Heart and Chest Hospital (copy) 1 CORONER I am David LEWIS, Assistant Coroner for the area of Liverpool and Wirral 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 28/07/2020 I commenced an investigation into the death of Brian Jackson aged 64. The investigation concluded at the end of the inquest on 14 July 2021. The cause of death found was: I a Neck compression I b Ligature hanging I c II The conclusion of the inquest was: Whilst affected by ongoing symptoms associated with post-operative delirium the Deceased hanged himself in hospital. 4 CIRCUMSTANCES OF THE DEATH Following major but successful heart surgery at Liverpool Heart and Chest Hospital, Thomas Drive, Broadgreen, Liverpool on16 July 2020 the Deceased developed symptoms consistent with delirium. On 23 July 2020 he was transferred from the Post-Operative Critical Care Unit to the Cedar Ward where (a few hours later) he used a ligature, which he had fashioned from pyjamas, to hang himself inside a locked bathroom. In doing so he sustained injuries from which he died at the scene, despite prompt medical attention. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) Following major heart surgery the Deceased spent a week on the Post-Operative Critical Care Unit, during which he presented intermittently with a range of symptoms which I was told in evidence constituted delirium, but were not consistently recognised or diagnosed as such by hospital staff. These symptoms were variously described as including confusion, agitation, severe paranoia and anxiety. On a number of occasions the Deceased’s was assessed using the tool known as CAM-ICU, which I heard is a nationally recognised diagnostic tool, in widespread use across the country. ON each occasion the result was negative for the purpose of delirium diagnosis, contradicting the view expressed in court to the effect that a diagnosis of delirium was appropriate. The hospital had its own policy concerning the management of patients at risk of delirium, the use of which depended in large measure upon a diagnosis being made. My impression was that the CAM-ICU results relied too heavily upon whether the patient was orientated in time and place, without allowing for a more complex cocktails of presentational symptoms to be taken into account. I was told by senior hospital staff that their investigation has revealed shortcomings in the efficacy of the CAM-ICU tool, notably in assessing the risk faced by patients with ‘hypo symptoms’ of delirium, or patients who produce a negative CAM-ICU result but present with edidence of paranoia. I heard details of extensive changes made by the hospital in its local arrangements and also that the hospital had approached NICE to ask if the CAM-ICU tool itself could be modified to take account of the lessons it had learnt in this case. I was told that the response from NICE was that use of the tool (and NICE guidance around this subject) had only recently been reviewed, in 2019, and is not to be reviewed again for some time. I am concerned that across the country an assessment tool remains in widespread use despite the problems identified and is likely to remain so for the indefinite future, meaning that patients at risk of delirium are not diagnosed or treated optimally. The outcome of this cases illustrates the gravity of the harm that can result. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 08 September 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: (widow and next of kin of the deceased) Liverpool Heart and Chest Hospital 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 David LEWIS Assistant Coroner for Liverpool and Wirral Dated: 16 July 2021
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.
2nd Floor
2 Redmond Place
London
E20 1JQ
United Kingdom
06 September 2021
Mr David Lewis
Assistant Coroner
Liverpool and Wirral Coroner’s Area
Gerard Majella Courthouse
Boundary Street
Liverpool
L5 2QD
Dear Mr Lewis,
I write in response to your correspondence, sent to NICE on 19 July 2021, regarding the
very sad death of Mr Brian Jackson. I would like to express my sincere condolences to his
family.
We have reflected on the circumstances surrounding Mr Jackson’s death, and the concerns
raised in your report.
In our guideline on delirium: prevention, diagnosis and management [CG103] we
recommend that all people in hospital should be observed, at least daily, for recent (within
hours or days) changes or fluctuations in usual behaviour. If any of these behaviour changes
is present, a healthcare professional who is trained and competent in the diagnosis of
delirium should carry out a clinical assessment to confirm the diagnosis (see
recommendation 1.4.1). Indicators of delirium are given in section 1.2 of the guideline and
healthcare professionals are advised to be particularly vigilant for behaviour indicating
hypoactive delirium.
For patients in critical care in whom indicators of delirium are identified, an assessment
should be carried out using the confusion assessment method for ICU (CAM-ICU) and that
this is undertaken by a healthcare professional who is trained and competent in the
diagnosis of delirium (see recommendation 1.5.1).
Liverpool Heart and Chest Hospital informed us that they were undertaking a root cause
analysis which was considering the ‘CAMS/ITU – RASS delirium risk assessment’. We
advised them that we had recently completed a review of CG103 and that we were going to
update the guideline, focusing on the risk assessment and diagnosis of delirium, including in
ICU settings. We also advised how they could engage with the development process and
send evidence to us for consideration during the update.
No diagnostic tool will ever be perfect, and during the development of the original guideline
the committee prioritised a test that had high sensitivity and would ‘rule in’ patients with
delirium.
We will consider the issues you have raised in your report during the update of the guideline.
Yours sincerely,
Chief executive
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