Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0399, written 25 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Nov 2021 |
|---|---|
| Reference | 2021-0399 |
| Deceased | Saif Hussain |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) · Alcohol, drug and medication related deaths · Product 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.
Classification: OFFICIAL-SENSITIVE REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive of Oxford University Hospitals NHS Foundation Trust Chief Executive’s Office Level 3, John Radcliffe Hospital Headley Way, Headington, Oxford, OX3 9DU. 1 CORONER I am Mrs Heidi J. Connor, senior coroner, for the coroner area of Berkshire. 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 I conducted an inquest into the death of Saif Mubeen Hussain on 19th November 2021. I recorded a conclusion of suicide 4 CIRCUMSTANCES OF THE DEATH The f amily asked me to refer to the deceased as Saif during the inquest. I will respect that wish in this report. Saif Hussain was born on 22nd January 1998. He had no recorded mental health history. Tragically, for reasons unknown to family, he Bracknell, Berkshire on 3rd June 2021 and was admitted to the John Radcliffe hospital later that day, but died there on 10th June 2021. His cause of death was polytrauma. in . He For the absence of doubt, the issues raised below in relation to the hospital management are unlikely to have played a part in causing Saif’s death, but I do consider that there is a risk of future deaths for other patients unless these issues are addressed. Saif was managed in the AICU from 4th to 7th June. On the 7th June, he was transferred f rom AICU to NICU. He had various infusions running, including a Heparin infusion. At the time of transfer, he was prescribed a dose rate of 1.4 ml/hour. Saif was also on a phosphate infusion, prescribed at 8.3 ml/hour. Whilst the prescribed doses remained the same, he was in f act administered a dose almost 8 times higher than that, namely 8.3 ml /hour. It seems likely that the rate prescribed for the phosphate infusion was mistakenly applied to Heparin. This matter has been investigated, and the trust has produced an excellent report. The evidence heard at the inquest, and within that report, show that: 1. Nurses working in a NICU do not routinely use anticoagulant medication. The nurses who started the wrong Heparin rate were not familiar with usual dosage rates. Classification: OFFICIAL-SENSITIVE 1 Classification: OFFICIAL-SENSITIVE 2. There were several nurses involved at that point, perhaps with a lack of ownership in terms of accuracy of the dose rate. This was also not double checked. 3. The Guardrails system (which would have prevented such an exceptionally high dose being administered) was switched off in order to allow the nurse/s to administer a rate of 8.3 ml/hour. 4. The systems in place at the time allow for the prescription rate and administration rate to be markedly different without that being flagged up. 5. Crucially, the hospital uses different computer systems in different parts of the hospital, to record patient records. The risks would clearly be much reduced, particularly for transfers within the hospital, by all departments being on the same system. We heard in evidence that the trust has always planned to consider amalgamation of the different IT systems. It is not for me to say which system they should or should not adopt. I accept that there may be advantages to the current system that were not explored during the inquest. I do however consider that there should be some focus on these issues within the trust, and an urgent review should be conducted. 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. The trust should consider : 1. A single system for record keeping and monitoring. 2. How the system could incorporate appropriate limits on the administration of certain drugs within that system. 3. Whether software like Guardrails should be implemented more widely, and consideration given to when and how it is possible to override this, and how that should then be documented. 4. Adopting a system of flagging up where prescription and administration of drugs is dif ferent. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 20 January 2022. 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 Classification: OFFICIAL-SENSITIVE 2 Classification: OFFICIAL-SENSITIVE I have sent a copy of my report to the Chief Coroner and to Saif’s 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 f orm. 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. I have also sent a copy of this report to the senior coroner for Oxfordshire, Mr Darren Salter. 9 25 November 2021 Mrs Heidi J. Connor Senior Coroner for Berkshire Classification: OFFICIAL-SENSITIVE 3
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.
The John Radcliffe Headley Way Headington Oxford OX3 9DU 13 January 2022 Mrs Heidi J Connor HM Senior Coroner for Berkshire Coroner’s Office Reading Town Hall Blagrave Street Reading RG1 1QH Dear Mrs Connor Regulation 28 Report / Prevention of Future Deaths Inquest into the Death of Saif Mubeen Hussain Thank you for your letter dated 25 November 2021 with the enclosed Prevention of Future Death Report. I am sorry that you have had cause to write to the Trust in this manner. We have reviewed the concerns raised in your letter and set out below our response: 1. A single system for record keeping and monitoring The Trust acknowledges there are multiple clinical systems making up the electronic patient record in the organisation. We accept the need to rationalise the number of clinical systems in use across our critical care units. This is likely to take to take at least two years to consider and implement. In the intervening period additional mitigations have been taken to address the identified risk and improve patient safety when a patient is moved from one intensive care unit to another. Clinical staff will be required to undertake a checklist to execute a safe handover. There are already procedures in place to mitigate for any loss of information on transfer from a CareVue using area (Adult Intensive Care Unit) to a Cerner using area (Neurosciences Intensive Care Unit) of the Trust. These include transcription of the CareVue drug chart into the Cerner system, the production of an intensive care discharge summary within the Cerner system, and more recently (July 2021) the automated upload of clinical notes generated within the CareVue system into the Cerner system. The last of these procedures has been put in place since Mr Hussain’s death. 2. How the system could incorporate appropriate limits on the administration of certain drugs within that system The Trust accepts the need to strengthen the decision support tools within the current clinical systems. We are looking to further improve the embedded system rules regarding drug prescription and administration. We have identified the need for the implementation of a ‘closed loop’ solution, that will remove some human elements of drug administration. The complete technical solution will be dependent on the rationalisation of the clinical systems into a single system (see point 1 above). The future single clinical system procurement process will include specifications to cover the automation of drug prescription to administration. 3. Whether software like Guardrails should be implemented more widely, and consideration given to when and how it is possible to override this, and how that should then be documented. The Trust is in the process of implementing infusion pumps with inbuilt dose error reduction software (DERS) throughout all clinical areas. Once the project has successfully been completed, clinical areas which use infusion pumps will utilise a medication library to infuse their drugs, if appropriate. The roll out schedule is such that all clinical areas will receive new infusion pumps by the end of the 2023 calendar year. The schedule has been prioritised based on each areas perceived risks, determined by factors such as clinical need, status and quantity of working equipment and staffing limitations which may affect training and implementation. Each medication library will contain a list of medications with specified concentrations and/or dosing safety limits to reduce the risk of infusion related incidents e.g., overdosing or underdosing. Resource will be allocated to ensure that medication entries on the libraries are accurate, relevant, and appropriate so that staff should not need to override safety limits if following usual practice; the software is designed not to be overridden if inappropriate dosing is entered outside of the safe limits put in place. However, in some exceptional circumstances outside the norm, it may be necessary for patient care to deviate from the specified dosing limits and therefore the infusion pumps offer the capability to infuse medication outside of the library where safety limits are not imposed. Staff will be educated that they must not work outside of the medication library unless in exceptional circumstances and an escalation process will be devised to enable a clear audit trail of all communication and decisions made between staff members which will be documented in the patients’ medical notes. This will be detailed in a standard operating procedure and will contain a flowsheet of the escalation process as a quick reference guide for staff members. A working group has been set up on NICU, who already use a medication library, to trial this. 4. Adopting a system of flagging up where prescription and administration of drugs is different. Many drugs delivered as infusions in critical care areas must have their infusion rates constantly adjusted to maintain physiological stability. As such, it is impractical for prescriptions to be changed to match the infusion rate each time the rate is altered by the bedside nurse. The issue raised refers to the current situation where a user can input a value for a drug infusion rate into the iView infusion section of the Cerner clinical system chart without any limits. This was identified as a contributing factor in the drug dosing error associated with Mr Hussain’s care. In the short term, we are investigating the possibility of developing a system which would put limits on the values which could be entered in this section of the chart for a select number of drugs with narrow dose safety profiles. This would initially include heparin, argatroban, vancomycin and insulin. In addition, the Trust is in the process of introducing new infusion pumps across all sites. One of the requirements for the procurement of these pumps was that they should allow bi-directional communication between the pumps and the Cerner clinical system. This would allow auto-programming of the pump from the electronic prescription and would automatically update the hourly infusion rate recorded in the iView infusion section of the drug chart. If the bi-directional communication capability of these pumps were to be used, this would significantly reduce the volume of manually entered data and remove the risk of transcription errors by bedside nurses when programming pumps or recording infusion rates. The Trust is looking at facilitating and funding this element of the new pump roll out in order to improve patient safety around administration of drug infusions in critical care. A second benefit of the new pumps is that each pump will contain a drug library. This is a database of drugs which aims to reduce the risk of underdosing or overdosing a drug. This forms part of the drug error reduction system described in point 3. I hope this response will help to assure you that the Trust is taking steps to review and explore clinical system options to improve patient safety in the areas you have identified. I would be grateful if a copy of this response can be shared with Mr Hussain’s family. Yours sincerely Dr Chief Executive Officer
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