Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0250, written 20 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 | 20 Jul 2021 |
|---|---|
| Reference | 2021-0250 |
| Deceased | Ben King |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Care Home Health related deaths |
| 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 DEATHS THIS REPORT IS BEING SENT TO: 1. Jeesal Akman Care Corporation Ltd Jeesal Holdings Ltd Jeesal Residential Care Services Ltd 16-18 High Street Dereham Norfolk NR19 1DR 2. Norfolk & Norwich University Hospital Colney Lane Norwich NR4 7UY 1. CORONER I am Jacqueline LAKE, Senior Coroner for the area of Norfolk 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 07/08/2020 I commenced an investigation into the death of Ben Buster KING, aged 32. The investigation concluded at the end of the inquest on 09/07/2021. The medical cause of death was: Acute Type II Respiratory Failure Obesity Hypoventilation Syndrome and Use of Sedative Medication Obesity Down's Syndrome, Obstructive Sleep Apnoea 1a) 1b) 1c) 1d) 2 The conclusion of the inquest was: Failure to diagnose obesity hypoventilation syndrome and inadequate consideration of the use of promethazine. Failure to identify the seriousness of a life- threatening situation. 4. CIRCUMSTANCES OF THE DEATH Ben was detained under the Mental Health Act at Jeesal Cawston Park (JCP) from 2018. His medical history included Down’s Syndrome, severe learning disability and sleep apnoea in respect of which he had used a CPAP machine but was not always tolerant. Ben’s weight as at June 2019 was recorded at 85.2 kg which had risen to 106 kg by June 2020. Ben attended at Norfolk and Norwich University Hospital (NNUH) on 9, 10th, 12th July 2020 following respiratory problems and was discharged to JCP. At 22.00 on 28 July 2020 Ben was given of agitation. In the early hours of 29th July 2020 Ben became unwell. At about 0700 CCTV showed Ben unresponsive. Emergency services were called at 07.07. Ben was taken to Norfolk and Norwich University Hospital where he was pronounced dead later that day. Promethazine, a sedative, as he was showing signs 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 could occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The matters of concern are as follows: JCP 1. Jeesal Akman Care Corporation (Directors: the care provider for JCP and closed in May 2021. However, Jeesal Holdings Ltd (JHL) and Jeesal Residential Care Services Ltd (JRCSL) and possibly other linked companies with the same Directors, continue to provide residential care to persons with mental health illness, learning disabilities, complex needs and physical disability. The concerns raised at the inquest could apply to residential care offered by these companies and unless such concerns are addressed there is a risk that future deaths may occur. It is not known if the Directors of these companies namely other companies providing care for persons with learning and other disabilities are Directors of any ) was 2. CCTV was shown at the inquest which revealed Ben King had been assaulted in the hours prior to his death and also that 1 to 1 observation was not carried out in accordance with the Observations Policy. CCTV is a reliable means of ensuring that staff comply with Policies and residents are treated with dignity. CCTV is not available in many if not all of the residential homes owned by JHL and JRCSL. 3. Basic dietary advice and guidance provided was not followed by staff. 4. The use of the Dietician in training of staff was reduced in 2017 from one day’s training to an 5. hour’s power point presentation Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations 6. Evidence was heard that exercise was not regularly offered to Ben King and when the Sports Instructor was absent for lengthy periods of time, there was no replacement 7. Multi-Disciplinary Team (MDT) Meetings were not held every 4 to 6 weeks as required. At MDT meetings which did take place, out of date weight measurements were recorded and relied upon for Ben. His increasing weight gain was not discussed at these meetings and weight loss was not set as a desirable or essential goal 8. JCP used the Pandora software system, (company Directors for Pandora are the same as for JHL and JRCSL) which is still used at the residential homes owned by JHL and JRCSL. Concerns were raised at the inquest in respect of this software system in that not all policies and documents were available to staff on the IPads provided, some of the documents were unwieldy and difficult to read (eg Personal Healthcare Plan), the Dietician recommended use of paper records in respect of Food and Fluid intake as these would be more accessible to staff and encourage the documents to be completed or in the alternative providing for the records on Ipads to be more easy to access and complete 9. The internal investigation carried out following Mr Ben King’s death did not capture the concerns raised at inquest 10. Evidence was heard that no substantive changes have been made at the residential homes owned by JHL and JRCSL following the death of Ben King and the closure of JCP to deal with these concerns NNUH 1. Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms. 2. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms. 3. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on the 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems 4. Advice given on discharge appears to be unclear and contradictory. The expert Respiratory Consultant referred to the advice as being “inadequate, unclear and inaccurate” On the Discharge Form provided on 9 July 2020 it is noted “Plan – home as Ben is back to normal, self, red flags and safety netting covered, to return in the event of any difficulty.” On discharge from ED on 10 July 2020 (second occasion) the hospital record states that Ben King is to return home, encouraged to lose weight, fluids are to be encouraged and “with no need to monitor his sats unless clinically unwell with sats in 60s%”. Not all of this information was included in the Discharge Form on 10 July 2020: The Discharge Form provided under “Other” - “seen by respiratory team, they are happy to send him home, they have clerked their advice on the paper. Cpap and O2” On 12 July 2020 the Discharge Plan provided “Home”. The advice from the Respiratory Consultant seen on 3 July 2020 was for CPAP to stop. Evidence was heard from the Care staff at JCP that they were unclear as to what the plan was with regard to Ben and specifically as to when Ben was to be returned to Hospital. One of the Doctors at JCP contacted the ED, NNUH to try to ascertain what the advice was and was unable to get any substantive response. Email contact was made with the Respiratory Team but no response was received until after Ben King’s death on 28 July 2020 5. The section headed “Drug History” was not completed on the Discharge Form on Ben King’s attendances on 9 or 12 July 2020. On 10 July, it states “nil significant”. This is despite Ben King being prescribed Promethazine, a sedative medication, affecting the respiratory system. Evidence was heard that not all prescribed medications could be expected to be included in “the small space” provided. That this is a medication where consideration would have been given to a risk vs benefit analysis but there was no evidence of any such analysis. Regulation 28 evidence was that not all medication can be listed; only “pertinent” medication. Promethazine would appear to be such a medication 6. Arterial and venous blood gas samples were taken from Ben King on his attendances on 9 and 10 July 2020, which the Respiratory Consultant said in evidence were incomparable (although this was not the evidence of the Expert Respiratory Consultant). No blood gas samples were taken on the 12 July 2020 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 09 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: , mother , father Dr Clinical Commissioning Group Norfolk Safeguarding Adults Review Group Care Quality Commission Department of Health HSIB Healthwatch - Norfolk 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. Dated: 20 July 2021 Jacqueline LAKE Senior Coroner for Norfolk Norfolk Coroner Service County Hall Martineau Lane Norwich NR1 2DH
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.
Jeesal Residential Care Services ltd 16-18 High Street Dereham, Norfolk NR19 1DR Web: www.jeesal.org Regulation 28: Response to report to prevent future deaths. Jacqueline LAK Senior for Norfolk, Norfolk Coroner Service County Hall Martineau Lane Norwich NR1 2DH Date: 4th September 2021 Reference Ben Buster King / Inquest/Reg28/Response Dear Jacqueline Lake, I am writing to you in your response to the regulation 28 report. Firstly, I would like to send my deepest condolences to the family relatives of Ben Buster King. The staffing team at Cawston Park worked hard to provide the care and support to Ben in his time at the Hospital and we were deeply saddened by his tragic death. I have requested from our Managing Director the regulation 28 report. His response is enclosed along with this letter. , to respond to the points within We as the non- executive directors of the board, namely and , have made further changes to the way our remaining care organisation operates. These changes are as follows: 1. The board membership will be balanced between executive and non-executive directors. 2. The board will seek independent verification of operational management reports. This task will be carried out by a non-executive director. 3. The Board will commission independent staff and family surveys. 4. Since closing the Hospital service in May 2021, we have taken the decision that we will not run Hospital services in the future. Your sincerely Jeesal Cawston Park 16-18 High Street Dereham, Norfolk NR19 1DR Email: info@jeesal.org Web: www.jeesal.org Following the tragic death of Ben King and the subsequent Inquest, the Coroner issued a report under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the coroners (Investigations) Regulations 2013. This letter is our response to that report. Each of the Coroner’s 10 points are responded to in turn. 1. The management of Jeesal Residential Care Services (JRCS) is led by , who has over 40 years of experience in the Health and Social Care sector, holding a number of senior appointments including CEO/MD in the public, independent and charitable sector. He also has a clinical background and significant management training and experience in the sector. He is not a shareholder in any Jeesal Company or subsidiary, nor any other private company in the Health and Social care field. He is not a statutory Director of any company or subsidiary owned in whole or in part by the Directors named in the coroner’s report. do not have any day-to-day responsibilities for the activities of Jeesal Residential Care Services, this is delivered through an Operational Management Team (OMT) which reports to the MD. In addition, the organisation has a Governance Assurance Team (GAT) which also reports directly to the MD. are Non-Executive Director of Jeesal Residential Care Services Board. The MD is currently seeking to strengthen the Board with the appointment of additional non-executive directors (NXD). JRCS is a community-based service for people with learning disability and or autism. our services are delivered in ordinary houses, sometimes adapted to meet the specific care needs of an individual. The services in the main are funded by the local authority and the residents have full access to the same community facilities as the rest of the local population. 2. CCTV is often used in hospital settings, though only in shared public areas. CCTV would be totally inappropriate in the residential homes that we manage. It could be considered an intrusion in the rights and liberties of residents, who consider the house as their home. Regular training, supervision of staff is key to good practice. In addition, internal and external inspection offer the opportunity to monitor that practice is both supportive and safe. Our residential services are overseen by a Service Governance Team (GAT), This team consists of a HR member, Training Manager, Head of Quality, Community Development Managers, Business Development Director and MD. They bring a wide Jeesal Care is the holding name for: Jeesal Residential Care Services Limited, Registered No: 04062939 Jeesal Support Services Ltd company number 08331750 Jeesal Residential Care Services range of experience and expertise to the role. They carry out planned and un-planned reviews of each service and develop with the home manager action plans, which they also monitor progress against. 3. Each home has access to an external multidisciplinary team- Community Learning Disability Team. Where there is a need for dietary advice then a referral is made to the team. The referral is made on an individual basis and any treatment and support plan will be shared and explained to the staff and monitored by the GAT and the CLDT In addition, every resident is registered with a local GP practice and therefore has full access through this route to community, primary and secondary care and treatment services made up of local health service and social care professionals. 4. The training of staff in Residential Services is very different from that in a hospital setting. There is a two-week induction programme in a classroom setting with additional e-learning modules. the training department also offers support for the Care Certificate, which is a nationally recognised award that all staff are required to complete to work in the service. 5. The residential service does not employ Dieticians, please see my response at point 3. We access this service through the residents GP or a referral from a member of the joint NHS/ LA Community Learning Disability Team (CLDT). This is in recognition that all of our residents live in our homes in the community. Many of our homes are ordinary houses scattered around the county. The people who live in our homes are very different from hospital patients their support focus is on everyday living skills and community integration and participation. 6. The MD and members of the GAT have access to every resident’s care file, we also have access to a whole range of information on each resident, all of which we can access remotely. The GAT carries out regular service reviews and unannounced inspections. Where there are deficiencies, the GAT will work with the Registered Manager to correct these deficiencies which may include report writing, care planning, risk assessments and healthy living plans. As an example, the GAT recently found inconsistencies in recording of information on Pandora, with some confusion as to record entries. This led to the establishment of a Pandora User Group, to work with homes to improve consistency of recording and content. We have also recently given access to the Pandora system to local authority professional staff so they can review the residents’ files. 7. Because our primary focus is community participation, we do not employ a Sports instructor. We encourage, wherever possible, for our residents to access community facilities including local gyms, swimming pools and a wide range of community activities. Each service user has a written care plan, this is developed with the individual and takes account of his / her preferences, interests, lies and dislikes, it will also involve input from external professionals. 8. Each resident is registered with a GP practice, who carry out a yearly health MOT on our residents. This covers weight management. This intervention and any Jeesal Care is the holding name for: Jeesal Residential Care Services Limited, Registered No: 04062939 Jeesal Support Services Ltd company number 08331750 Jeesal Residential Care Services recommendations from it are shared with the Manager and staff of the resident’s home and incorporated into the resident’s care plan. If required a referral is made to secondary health services or to the CLDT. The CLDT have nurses who can advise and support on healthy lifestyles and will monitor progress. They are also have the expertise to support home staff in a whole number of general health and mental health issues and where necessary they can refer a resident to another member of the team. The CLDT also carry out regular out-patient appointments, led by a Consultant Psychiatrist and any interventions or onward referrals would be agreed and actioned from this appointment. 9. The Pandora system is still under development in Residential Services. We have recently strengthened and improved our systems, having taken learning from the issues at Cawston Park. This includes the creation of Pandora User Group. This group involves home staff to ensure that the Pandora Information System is accessible and useful to staff teams in the homes. However, we have to strike a balance between ensuring we capture essential information and not creating too much information. This is a task for the Pandora User Group. 10. Access by our staff for policies and procedure is via a different system called My Learning Cloud. Every member of staff when joining the organisation is given an account on My Learning Cloud to track their training, access Policies and Procedures and a range of staff focused activities. Another learning for us is the setting up of a Pandora user group, which is a recent development. This is a cross section of staff in the organisation to look at the further development of Pandora, how we ensure it is user friendly and what additional training is required by staff to ensure easy access to the system. We note the suggestion by the Dietician to have a paper-based system. We am resistant to this as this will undermine my ability and the ability of GAT and external colleagues to monitor remotely. I consider a two-system approach to be detrimental when trying to achieve a whole system approach to care and support. Unlike a hospital where the patients are in one place, our residential services are spread across the county and as such, while physical attendance at a home is important, so too is remote access. In addition, the Pandora system allows us to carry out statistical analysis and monitor trends. 11. The coroner is correct the investigation did not capture the concerns raised in the inquest. However, the investigation was halted due to the matter becoming a Police Investigation and as such common practice is any internal investigation is suspended to ensure it does not compromise the Police enquiry. I am satisfied that if we had been allowed to proceed all of the issues would have been identified by the investigating officers. 12. Our Head of Quality regularly reviews our SI and RCA procedures in the light of updated guidance. Where guidance changes then the Head of Quality will update our Policy and procedures in this area. The Service Governance Committee is required to ratify the changes and only then will the MD sign it off. Jeesal Care is the holding name for: Jeesal Residential Care Services Limited, Registered No: 04062939 Jeesal Support Services Ltd company number 08331750 Jeesal Residential Care Services 13. The residential homes have learned the lessons where applicable from the experiences of Cawston Park and from other investigations of a similar nature. The main area of lessons learnt was in the area of information sharing with professional colleagues. This still requires more work, and the MD meets regularly with Managers in NCC and the CLDT and takes forward personally any shortfalls in this area, referring them to the individual home manager to address or to the GAT to give support, guidance and support However, the delivery of services in the community are very different in their style and function as well as purpose. The majority of people in hospital are held under a section of the Mental Health Act and in some cases, they have additional Home Office restrictions upon them. This is not the case in residential services. In addition, a patient in a hospital is subject to management of their treatment by a Responsible Clinician, usually a Consultant Psychiatrist. This is not the case for the majority of people living in the community, nor should it be. However, with our external colleagues in Social Services we have being carrying out a review of each resident in our homes to ensure they are correctly placed, and the care package is appropriate to meet their needs. We have also ensured that residents in our homes are considered for a different service due to changing needs. We are working with our health and social services colleagues to seek ways of improving the care and support of our residents from external professionals and additional training for our staff. We meet weekly with our Social Services Colleagues and a rolling action plan is in place. Hospitals by their very nature are much more comprehensive in the way that care, and treatment is delivered, the majority of staff including the Multi-Disciplinary Team (MDT) are employed by the organisation that owns the hospital. However, the operational framework in the community is based on shared care with a range of organisations and professionals, this arrangement ensures that the necessary checks and balances are in place. The operational functioning of a hospital is alien to the workings of residential services and to the people we support. While lessons can be learned from any enquiry, it does not necessarily follow that sweeping changes should be made in residential services unless those changes emanated from a review of residential services elsewhere. In which case there would undoubtably be valuable lessons to learn. the people that are supported, the staff the management and the collaborative working in our services demonstrate that we are well ahead of the workings of a hospital setting. Hospital systems and processes are often not relevant to the way services are delivered for our residents. Managing Director Jeesal Residential Care Services. Jeesal Care is the holding name for: Jeesal Residential Care Services Limited, Registered No: 04062939 Jeesal Support Services Ltd company number 08331750 Jeesal Residential Care Services 1st September 2021 Jeesal Care is the holding name for: Jeesal Residential Care Services Limited, Registered No: 04062939 Jeesal Support Services Ltd company number 08331750
' , To provid~: cw.ry p,Aii::nt ·:.1ith the cJre \·,re war t for those we love irie most Ms Jacqueline Lake Senior Coroner for Norfolk Norfolk Coroner Service County hall Martineau Lane Norw ich Nl~ 'i 2DH By e-mail only r,r;-z--r-:;J Norfolk and Norw ich University Hospitals LLLU':"_j Office of the Chief Executive Norfolk & Norwich University Hospitals NHS Foundation Trust l\!orvvich Research Park Colney Lane r--!R4 7UY www . nn uh. nh s. uk Norwich 15 November 2021 Dear Madam Regulation 28 response - touching the death of Ben King I am writing in response to the Regulation 28 report that I received on 23 July 2021 . I hope that this letter will satisfy you that the matters of concern raised in the Report have been carefully considered by the Trust and appropriate action has been or is being taken. The Report raises 6 areas of concerns regarding the Norfolk and Norwich University Hospital. Our response in relation to each of these is set out below: 1. Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms. Dr (Emergency Department Consultant and Clinical Governance Lead for ED) confirms that the medical records for 10 July 2020 make reference to Mr King 's attendance on 9 July 2020. Under the section of those records headed "History of presenting condition" (Medical records Bundle D page 14) the ED doctor recorded "had presented to ED yesterday was assessed and went home ... " As part of the medical records , this information would have been available to the Respiratory Medicine Team when Mr King was assessed by the Respiratory Registrar. It is understood that the Registrar did not specifically reference this information when then presenting a summary of the relevant facts to the consultant. The amount of information to include when making a clinical case presentation will vary from patient to patient depending on the particular facts at the time. Dr (Consultant Respiratory Physician) advises that the previous attendance to A&E would not be an indication for admission; although this is helpful information, it is the circumstances , clinical assessment and investigation results which are the main deciding factors. That said, the importance of effective communication is clearly recognised and to promote good quality handovers the Respiratory team now hold a daily morning report meeting , attended by all the on-call specialities. At these meetings cases are discussed and referred to other specialities as appropriate. 2. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms. tO U·1e Emei·g ei-1cy Our Oil-call resp iratory pi1ys icia il s ai·e avai lable to prov id e advice Departm ent doctors as requ ired and the ED staff so ught su ch advi ce with respect to Mr King's case when he presented on 10 July 2020. When to seek such specialist advice is a matter of clinical j udgment and it was not considered necessary to make a furthe r referral to the Respiratory Physicians for advice with respect to the same patient and same sym ptoms on ly two days later. This case has however been discussed through the ED clin ical governance process to ra ise awa reness of th e rare diagnosis of obesity hypoventilation syndrome which can deve lop from obstructive sleep apnoea. 3. At the time of Ben King's attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on the 3 July 2020. The Respiratory Team was not made aware of Ben King's attendances at ED on 9, 10 or 12 July 2020 with respiratory problems It is documented that the on-call Specialist Respiratory team were contacted on 10 July 2020 and they assessed Mr King accordingly. (Medical records Bundle D pages 15, 20 and 21). 4. Advice given on discharge appears to be unclear and contradictory. The expert Respiratory Consultant referred to the advice as being "inadequate, unclear and inaccurate" • On the Discharge Form provided on 9 July 2020 it is noted "Plan - home as Ben is back to normal, self, red flags and safety netting covered, to return in the event of any difficulty;" • On discharge from ED on 10 July 2020 (second occasion) the hospital record states that Ben King is to return home, encouraged to lose weight, fluids are to be encouraged and "with no need to monitor his sats unless clinically unwell with sats in 60s%". Not all of this information was included in the Discharge Form on 10 July 2020: The Discharge Form provided under "Other" - "seen by respiratory team, they are happy to send him home, they have clerked their advice on the paper. Cpap and 02" • On 12 July 2020 the Discharge Plan provided "Home". The advice from the Respiratory Consultant seen on 3 July 2020 was for CPAP to stop. Evidence was heard from the Care staff at JCP that they were unclear as to what the plan was with regard to Ben and specifically as to when Ben was to be returned to Hospital. One of the Doctors at JCP contacted the ED, NNUH to try to ascertain what the advice was and was unable to get any substantive response. Email contact w as made with the Respiratory Team but no response was received until after Ben King's death on 28 July 2020 in to clinicians the Community and The importance of clear liaison and communication between hospital and community teams is obvious and the Hospital has accordingly made its electronic results system (ICE) available they can access correspondence, such as discharge letters. This is however only an initial step towards enhancing the digital capability of our Norfolk healthcare system which unfortunately is one of the least digitally developed of any in the country. We know that establishing comprehensive and robust lines of communication will be hugely enhanced by establishing an electronic patient record (EPR) system of the type used in many other areas of the NHS. We are in active discussions with regional and national colleagues to develop the case for the EPR across Norfolk and Waveney. this route through In the meantime, to minimise the risk to patients:- 2 • • the Hospital has put in place a system for GPs to contact the Hospital if information is unclear - via a nhs.net email account, which is manned 24/7 by the ED admin team, who seek the most appropriate person to respond; the entire ED team have been reminded to check with carers, relatives and patients that the discharge advice is clear and understood so that people know what to do if the patient's condition does not improve; , • we have appointed an Associate Medical Director with a particular role to enhance liaison between hospital and clinicians in the community/primary care . The position with respect to discharge letters is a regular topic of discussion at Service Director meetings and is part of the monthly Performance Assurance Framework (PAF). 5. The section headed "Drug History" was not completed on the Discharge Form on Ben King's attendances on 9 or 12 July 2020. On 10 July, it states "nil significant". This is despite Ben King being prescribed Promethazine, a sedative medication, affecting the respiratory system. Evidence was heard that not all prescribed medications could be expected to be included in "the small space" provided. That this is a medication where consideration would have been given to a risk vs benefit analysis but there was no evidence of any such analysis. Regulation 28 evidence was that not all medication can be listed; only "pertinent" medication. Promethazine would appear to be such a medication. Given the length of time that Mr King had been taking the Promethazine medication, in the clinical judgment of the doctors that saw and assessed Mr King, this was not considered likely to be a cause of Mr King's decline and attendance at the ED. Changes/recommendations with regard to Mr King's psychiatric medication were therefore not specified. Obesity hypoventilation syndrome is a rare condition that the ED team had not come across before. An adverse link with Promethazine has been highlighted amongst the team through the departmental clinical governance process, to inform their assessment of future patients. 6. Arterial and venous blood gas samples were taken from Ben King on his attendances on 9 and 10 July 2020, which the Respiratory Consultant said in evidence were incomparable (although this was not the evidence of the Expert Respiratory Consultant). No blood gas samples were taken on the 12 July 2020 As detailed in the medical documentation, on 9 July 2020 a capillary blood test was performed and Mr King declined further blood testing (medical records bundle D page 3). On 10 July 2020 Mr King agreed to ·undergo further blood testing and an arterial blood gas was obtained. The tests performed on 9 & 10 July were therefore different. Arterial blood sampling is a medical procedure that requires particular clinical skills. It can be painful and hazardous, with a number of potentially serious complications for the patient, recognised as: • Local hematoma (bruising) • Damage to the blood vessel. • Arterial occlusion (blockage) • Infection at the puncture site • Air or thrombus embolism • Anaphylactic reaction to local anaesthetic This is therefore to be exercised only with specialist equipment available and in appropriate the patient's clinical circumstances based on clinical assessment and circumstances at the time. It is not appropriate for this to be reduced to a prescriptive list. The ED team have however discussed Mr King's case and raised awareness generally of the judgment of 3 importance of obtaining tests when they are needed to inform the management and next stage of a patient's treatment. hope tr1at this information provides you wiU1 u-1e necessary assurance that the Trust l1as considered Mr King's case carefully. It was acknowledged by HM Coroner's expert - Dr - that there was a spectrum of decision making available in this case , with admitting Mr King at one end of the range and sending him home at the other end. The clinical teams have welcomed the opinion opportunity to discuss this difficult and complex case. They have considered Dr carefu lly so that the y can bring understand ing of that range of opinions to bear when treating future patients. Yours sincerely Chief Executive 4
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