Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0348, written 18 Oct 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Oct 2021 |
|---|---|
| Reference | 2021-0348 |
| Deceased | Mohammed Salam |
| Coroner | Julie Robertson |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, The Northern Care Alliance NHS Trust CORONER | am Julie Robertson, Assistant Coroner for the Coroner area of Manchester North T CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On 9 April 2021 an investigation into the death of Mohammed Abdus Salem was commenced. The investigation concluded at the end of the inquest on 14 October 2021, | recorded a conclusion of death by natural causes. CIRCUMSTANCES OF DEATH The.deceased was diagnosed with chronic myelomonocytic leukaemia (CML) in October 2020. This illness was managed conservatively and the deceased required and received regular blood transfusions and oral chemotherapy to maintain control of his white cell count. The deceased’s health remained stable until March 2021 when his condition deteriorated significantly. It was noted that the deceased’s CML had rapidly progressed. On 29 March 2021, the deceased was admitted to the Royal Oldham Hospital for inpatient treatment. He was treated with intravenous fluids and antibiotics and his oral chemotherapy medication dose was increased. By 31 March 2021 the deceased's condition had further deteriorated. He was commenced on Rasburicase to reduce the risk of him developing tumour lysis syndrome. While it was intended that the deceased receive a further dose of Rasburicase on 1 April 2021 this drug was not given despite high urate levels being detected. This was medication that could either be administered as a single dose or as part of a longer course. | heard evidence that the prescribing doctor intended that the Deceased receive more than one dose however this was not specified in the notes or in the prescription. The clinicians who reviewed the deceased on 1 April 2021 assumed that only one dose was required. During the late evening of 1 April 2021, the deceased was discovered unresponsive. His death was confirmed shortly afterwards on 2 April 2021. It is more likely than not that had a further dose of Rasburicase been administered to the Deceased on 1 April, his life would have been prolonged by up to 48 hours. CORONER’S CONCERNS 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 is as follows:- 1. The Root Cause Analysis (RCA) undertaken by the Northern Care Alliance identified that a dose of Rasburicase had not been administered on 1 April 2021 however it did not consider any of the factors that gave rise to that omission or its consequences. My concern is that the RCA fell short of the required standard of rigour which leaves residual questions as to organisational governance standards and learning from death. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 13 December 2021 |, Julie Robertson, the Assistant 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. 4} | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- 1. Family of Mohammed Abdus Salam 2. The Care Quality Commission | 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 from. 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. _ | Date: 18.10.21 Signed: On O_—
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.
Chief Medical Officer/Deputy Chief Executive Group Headquarters 3rd Floor Mayo Building Stott Lane Salford M6 8HD 10 December 2021 Ms J Robertson Assistant Coroner Manchester North Sent via email Dear Ms Robertson Re: Inquest touching the death of Mr Mohammed Abdus Salam I write further to the above matter following receipt of your Regulation 28 report dated 14th October 2021. This correspondence constitutes the Northern Care Alliance NHS Group response to that report. I would like to emphasise that I fully support the use of Regulation 28 reports as an important mechanism for learning and that as an organisation we are continuously looking for ways to improve patient safety. I am therefore grateful to you for sharing your concerns that our investigation into the sad death of Mr Salam did not satisfactorily address the factors associated with the prescribed medication Rasburicase. We have reviewed our internal investigation, improved our learning, and agreed actions to prevent such recurrence in the future. Our Haematology consultants have explained that Rasburicase may be prescribed either as a “stat” dose, in which case the need for further doses should be evaluated within 24 hours, or as a continuous course of treatment for a defined period of time. Review of the Grand Round notes pertaining to Mr Salam on 31 March 2021 shows a recommendation for a single 3mg dose of Rasburicase. There is no written plan for further doses. On the electronic prescribing system (ePMA) it was also prescribed as a “stat” dose with no follow- on instructions. The attending consultant’s intention had been for the drug to be given on a continuous basis. This discrepancy between the consultant’s intention and the written documentation demonstrates the need to ensure that our processes for clinical reviews and ward rounds are robust so that patient plans are well documented and consequently well communicated within the team. Please see below the issues that we have identified and our plans to address them: Issue: To ensure that clinical management plans are well recorded and communicated. Action: The attending consultant will countersign the recorded outcome of ward rounds to verify the accuracy of the review and the management plan. This process has been implemented following communication to clinical colleagues on 6th December 2021. Issue: Review of medications must be an integral part of ward rounds and patient reviews. Action: Grand round and weekend handover proformas will be updated to include a check box and consultant countersignature to record that ePMA has been reviewed. This has been implemented following communication to clinical staff on 6th December 2021. I have taken the liberty of enclosing a copy of the updated proforma for assurance. Both the above remedial actions will be audited for compliance in 3 months’ time and added to the official departmental work programme which is monitored through the Cancer & Complex Medicine Governance Meeting Issue: The RCA identified a lack of awareness of management of tumour lysis syndrome. Action: The section on tumour lysis syndrome has been updated in our junior doctors’ handbook. We further plan to introduce a specific guideline for the management of tumour lysis syndrome and the use of Rasburicase to be available on the Trust Intranet. To be reviewed and approved at the Cancer & Complex Medicine Governance Meeting on 21st January 2022. Issue: The need to ensuring robust address of any medication issues in all RCAs. Action: Pharmacy input to the RCA will be mandatory whenever medication issues are identified to ensure objective and expert review. This has been communicated to Divisional Clinical Governance Managers and Divisional Leadership teams by the Medical Director The actions detailed above will improve our clinical and governance processes and mitigate recurrence. We hope that we have addressed your concerns. Yours sincerely Consultant Emergency Medicine Chief Medical Officer and Deputy Chief Executive
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