Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0162, written 13 May 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 May 2022 |
|---|---|
| Reference | 2022-0162 |
| Deceased | Rita Britten |
| Coroner | John Broadbridge |
| Coroner area | West Yorkshire Western |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
IN THE WEST YORKSHIRE (WESTERN) CORONER’S COURT IN THE MATTER OF: RITA GIULIANNA NICOLA BRITTEN The Inquest Touching the Death of Rita Giulianna Nicola BRITTEN A Regulation Report – Action to Prevent Future Deaths __________________________________________________________ REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 NHS ENGLAND 2 RESUSCITATION COUNCIL 3 …………………………………… 4 …………………………………… 1 CORONER I am John BROADBRIDGE Assistant Coroner for the area of West Yorkshire (Western) 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 First October 2018 I commenced an investigation into the death of Rita Giulianna Nicola BRITTEN (“Mrs Britten”) aged 54. The investigation concluded at the end of the Jury inquest begun on 9 May ending on 13 May 2022. The jury recorded “Mrs Rita Britten died at Pinderfields Hospital on 29 July 2018 after life support was withdrawn. This was a direct result of a choking incident on 26 July at the Priestly Unit” The conclusion of the Jury as to the medical cause of death was: “I a Hypoxic Brain Injury I b Cardiac Arrest I c Upper Airway Obstruction Secondary to Food Bolus (choking) II “ Their Conclusion was expressed in the form of a questionnaire which is attached to this Report but the Jury included the words at Part 4 of their Record of Inquest: “-lack of communication/insufficient handover between staff -System shortfalls in recording updating and accessing key information -Risk assessments incomplete -Inadequate first aid training” 4 CIRCUMSTANCES OF THE DEATH Mrs Britten was a detained patient under s3 MHA 1983. She choked while trying to bite off and swallow pieces of fresh apple. Despite efforts at rescue and resuscitation on the Ward where she was detained, she died later in Hospital without regaining consciousness from the effects of occlusion of airway. She was 15 stone or so in weight with a BMI last assessed at 31 (“obese”) Abdominal thrusts otherwise “Heimlich Manouevre” (“conventional abdominal thrusts”)(after backslaps) to assist in ejection of material were indicated to be difficult if not impossible because of her body shape/size. An unusual manoeuvre of inversion of her body over the upright of an upholstered chair was also attempted; all attempts met with limited ejection of material from the airway. A larger piece of apple was eventually removed by forceps used by an attendant ambulance operative before adrenaline created ROSC but GCS was at 3/15 en route on pre alert emergency to Hospital, despite increase in her respiratory effort, and remained so. 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) The concern is of want of clear guidance on the steps to be taken to most effectively rescue the individual from the urgent and developing choking emergency when that individual does not conform to the competent adult to whom conventional abdominal thrusts are possible or might be effectively applied. In particular, this concern relates to but is not limited to the overweight/obese/bariatric individual (however that may be best described). a) There should be clear national emergency /resuscitation guidelines for dealing effectively with choking incidents where the individual is overweight/obese or otherwise where “conventional abdominal thrusts” are not possible or are less able to be effectively applied. In Mrs Britten’s case a significant element of early rescue techniques was compromised. It is perceived this will be an increasing present and future risk in the UK population due to obesity. b) There should be early review and assessment of papers that discuss the efficacy (or otherwise) in such circumstances of “inversion” of the affected choking individual said to be set out in: Hubert Blaine et al in American Journal of Medicine ref, Am J Med 2010 Dec; 123 (12) And “Effect of body position on relieve of foreign body from the airway”, Artur Luczak AIMS Public Health 6(2): 154-159 And how this or similar technique(s) might have application in the Hospital/clinical setting in which this choking episode occurred. c) There should be identified and assessed any specialist equipment to assist in these circumstances. 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 July 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons and South West Yorkshire Partnership NHS Foundation Trust And …………………………………………………………………………………………………………………… 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 John BROADBRIDGE HM Assistant Coroner for West Yorkshire Western Coroner Area Dated: 13 May 2022
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.
John Broadbridge HM Assistant Coroner for West Yorkshire Western Coroner Area City Courts The Tyrls Bradford BD1 1LA National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 05 August 2022 Dear Mr Broadbridge Re: Regulation 28 Report to Prevent Future Deaths – Rita Britten who died on 29 July 2018. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 13 May 2022 concerning the death of Rita Britten on 29 July 2018. I would like to express my deep condolences to Rita’s family. I note the inquest concluded Rita’s death was a direct result of a choking incident on 26 July 2018. Following the inquest, you raised concerns in your Report that there should be clear national emergency/resuscitation guidelines for dealing effectively with choking incidents where the individual is overweight/obese or otherwise where “conventional abdominal thrusts” are not possible or are less able to be effectively applied. You stated that there should be early review and assessment of papers that discuss the efficacy in such circumstances of “inversion” of the affected choking individual and how this or similar techniques might have application in the hospital/clinical setting in which this choking episode occurred. You have added that there should be specialist equipment to assist in these circumstances. I note that you also sent your Report to the Resuscitation Council UK and I have had sight of their response. I am assured that Resuscitation Council UK have addressed all the concerns raised in your Report. Although the circumstances surrounding this case are not specifically within NHS England’s sphere of statutory responsibility, I have brought the matters of concern to the attention of colleagues across our National Patient Safety Team (NPST) to support any general work around safety and quality of care in this area. I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by a Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely, National Medical Director NHS England
John Broadbridge
HM Assistant Coroner West Yorkshire(Western),
HM Coroners Office,
1, Cater Street,
Bradford
BD1 5AS
27 June 2022
Dear Sir,
Re: Rita Britten, deceased
Report to Prevent Further Deaths
Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
Thank you for contacting Resuscitation Council UK in relation to your enquiries into the death of Rita
Britten. We are sorry to learn of the circumstances leading to Mrs Britten’s death and would like to
express our condolences to her family.
Resuscitation Council UK exists to save lives by developing guidelines, influencing policy, delivering
courses and supporting cutting-edge research related to cardiac arrest. Through education, training and
research, we’re working towards the day when everyone in the country has the skills they need to save a
life.
We have considered the information provided in the Regulation 28 report and respond to your specific
questions as set out below.
a) There should be clear national emergency/resuscitation guidelines for dealing effectively with
choking incidents where the individual is overweight/obese or otherwise where “conventional
abdominal thrusts” are not possible or are less able to be effectively applied. In Mrs Britten’s case
a significant element of early rescue techniques was compromised. It is perceived this will be an
increasing present and future risk in the UK population due to obesity.
Resuscitation Council UK sets outs its guidance for the management of foreign body airway obstruction
('choking') in our basic life support guidelines.1 These guidelines are drawn from the recommendations
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of the European Resuscitation Council2 and International Liaison Committee on Resuscitation3 based on
a recent systematic review of published research.4
Guidelines need to balance the need for urgent and effective treatment of foreign body airway
obstruction with the risks of harm (sometimes fatal) from the application of those interventions.4 They
must also be easy to implement to enable early treatment of choking. Unfortunately even when
attempted, the interventions will not always be successful and lead to survival in every case.
The guidelines support a step wise approach, starting with encouraging the person to cough, before
progressing to back blows and abdominal thrusts. If these interventions are unsuccessful and the
person becomes unconscious then chest compressions are recommended.
Chest compressions in the supine position (on their back) typically raise intrathoracic pressure to a
greater extent than abdominal thrusts.5 They can be delivered irrespective of the persons size as it does
not require the rescuer to encircle their arms around the person as is required for abdominal thrusts.
Figure showing how chest compressions are
administered. The technique is feasible in
persons with increased body mass index.
In preparing our guidance we considered the use of abdominal thrusts with the person lying on their
back but decided not to include them given that chest compressions are probably more effective and our
assessment that there is a higher risk life threatening abdominal injuries from the use of the abdominal
thrust.
We will include a frequently asked question on our national website which highlights our position.
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b) There should be early review and assessment of papers that discuss the efficacy (or otherwise)
in such circumstances of “inversion” of the affected choking individual said to be set out in Hubert
Blaine et al in American Journal of Medicine ref, Am J Med 2010 Dec; 123 (12)
And “Effect of body position on relieve of foreign body from the airway”, Artur Luczak AIMS Public
Health 6(2):154-159
The European Resuscitation Council guidelines, upon which the UK guidelines are based, reviewed the
role of these techniques which have been variously described as a chair/table manoeuvre. The view
from the expert writing group was that these interventions lack sufficient evidence for their introduction
into the guidelines at the present time. Resuscitation Council UK shares a similar view and also
highlights concerns in relation to the safe manual handling of larger persons using these techniques
which pose risks of injury to both patient and rescuer. As set out above, our view is that if abdominal
thrusts are unsuccessful or cannot be administered, the rescuer should progress to chest compressions.
c) There should be identified and assessed any specialist equipment to assist in these
circumstances.
Our guidelines recommend that healthcare professionals use a laryngoscope (a device put in the mouth
with a light on the end) and Magill’s forceps (like pincers) to remove the foreign body under direct vision.
Our recommendations are informed by our experience as well as published evidence demonstrating this
can be an effective technique.4
The use of this technique is specifically taught in our advanced life support course (Cardiac Arrest
Simulation Teaching Scenario 4).
Our quality standards for mental health inpatient care include the recommendations that this equipment
is immediately available
https://www.resus.org.uk/library/quality-standards-cpr/quality-standards-mental-health-inpatient-care-
equipment-and-drug
We have also assessed the evidence for suction-based airway clearance devices but consider there is
insufficient evidence currently about either their safety or effectiveness, to advocate for their routine use.
This view is aligned with the 2022 Evidence update on this topic from the International Liaison
Committee on Resuscitation.
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We hope that the information contained in our response has been helpful. Please do not hesitate to
contact us if you have any further questions.
Yours sincerely
MD FRCP FFICM FERC FIMC RCS(ed) FMedSci
Chair Community and Ambulance Resuscitation Committee
On behalf of Resuscitation Council UK
References
Olasveengen TM, Semeraro F, Ristagno G, et al. European Resuscitation Council Guidelines
Resuscitation Council UK. Adult basic life support Guidelines. 2021.
Olasveengen TM, Mancini ME, Perkins GD, et al. Adult Basic Life Support: International
1.
https://www.resus.org.uk/library/2021-resuscitation-guidelines/adult-basic-life-support-guidelines.
2.
2021: Basic Life Support. Resuscitation 2021; 161: 98-114.
3.
Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With
Treatment Recommendations. Resuscitation 2020; 156: A35-A79.
4.
review of interventions. Resuscitation 2020; 156: 174-81.
5.
Heimlich manoeuvre in recently dead adults with complete airway obstruction. Resuscitation 2000;
44(2): 105-8.
Langhelle A, Sunde K, Wik L, Steen PA. Airway pressure with chest compressions versus
Couper K, Abu Hassan A, Ohri V, et al. Removal of foreign body airway obstruction: A systematic
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Tavistock Square, London WC1H 9HR
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