Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0361, written 14 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Nov 2022 |
|---|---|
| Reference | 2022-0361 |
| Deceased | Ghulam Mohammad |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS Trust · Whipps Cross University Hospital NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MR G IRVINE SENIOR CORONER EAST LONDON East London Coroners, Queens Road Walthamstow, E17 SQP REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Ref: 15653789 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: • • Whitechapel Road, Whitechapel, London, E1 1BB Chief Executive, Barts Health, Royal London Hospital, Care 39 Victoria St, Westminster, London SW1 H 01:U The Secretary of State for Health & Social 1 CORONER I am Graeme Irvine, senior coroner, for the coroner area of East London 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) Re~gulations 2013. httQ:LLwww.legislation.gov.ukLukQgaL2009L2SLscheduleL5LQaragraQhL7 httQ:LLwww.legislation .gov.ukLuksiL2013L1629LQartL7 Lmade 3 INVESTIGATION and INQUEST On 19th October 2021 I commenced an investigation into the death of Ghulam Mohammad age 89 years. The investigation concluded at the 1end of the inquest on 19th April 2022 and 6th October 2022. I made a determination of a narrative conclusion : Mr Ghulam Mohammad was admitted to hospital on 9th October 2021 . Whilst an inpatient he suffered a fall on 11 th October 2021 , he died as a consequence of injuries sustained in that fall on 18th October 2022. Mr Mohammed's medical cause of death was determined as; 1 1 a Subdural Haematoma 1 b Community Acquired Pneumonia 1c II Chronic Kidney Disease, Type 2 Diabetes Mellitus, Hypertension 4 CIRCUMSTANCES OF THE DEATH Ghulam Mohammed was an 89-year-old man admitted to hospital 9/10/21 by ambulance following an unwitnessed fall. On admission his blood results showed ; coagulopathy and acute kidney injury . Imaging showed no intra-cranial bleed but was suggestive of pneumonia and faecal impaction. He was treated with IV fluids an anti-biotics . Mr Mohammed was prescribed Vitamin K after discussion with Haematology. On 11/10/21 Mr Mohammed sustained a fall in the bathroom causing a head injury , he became more confused . Following a medical review an urgent CT head was requested . A CT head was not undertaken until 15/10/2021 , a four-day delay. Prior to undergoing the CT head - Mr Mohammed was prescribed low molecular weight heparin , a prophylactic against the risk of venous thromboembolism which impedes clotting function. The CT head identified a large right-sided subdural haematoma with a mid line shift. Following neurological advice conservative management was given , the patient's condition deteriorated and he sadly passed away on the 18/10/2021 . 5 CORONE~SCONCERNS 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 . - 1. A patient with a high risk of falls sustained a fatal injury in an avoidable fall in hospital. 2. Following that fall , an urgently requested CT head was delayed for four days. 3. Before the requested CT head was undertaken , a doctor prescribed blood thinning medication - enoxaparin to Mr Mohammed . Enoxaparin can exacerbate an intra-cranial bleed . The medication was administered on 13 & 14th October 2021 . Both the prescription and the administrations of enoxaparin were made without knowing the extent of any intra-cranial damage caused by the fall on 11/10/21 . Inadequate record keeping meant that there was no contemporary account of the factors taken into consideration by the doctor or her supervising consultant in prescribing enoxaparin . 4. 5. Neither the Trust's initial SI investigation nor the consultant statement to the inquest mentioned the use of enoxaparin or the lack of clinical records justifying its use . 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 2 [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 9th January 2023. 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 the family of Mr Mohammad , the General Medical Council and the CQC. I have also sent it to the local Director of Public Health who may find it useful or of interest. 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 or of interest. believes may find it useful You may make representations to me, the coroner, at the me of your response , about the release or the publication of your response . ( / 9 [DATE] 14/11/2022 [SIGNED BY CORONER] d V /1 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.
From Maria Caulfield MP Parliamentary Under Secretary of State for Mental Health and Women's Health Strategy Department of Health & Social Care 39 Victoria Street London SW1H 0EU Mr Graeme Irvine Senior Coroner East London East London Coroner's Court 124 Queens Road Walthamstow E17 8QP 13 May 2024 Dear Mr Irvine, Thank you for your Regulation 28 report to prevent future deaths dated 31/10/2023 about the death of Ghulam Mohammad. I am replying as Minister with responsibility for patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Mohammad’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter. Your report raises concerns over an avoidable fall in hospital and following that fall, an urgently requested CT head was delayed for four days. Before the requested CT head was undertaken, a doctor prescribed blood thinning medication enoxaparin to Mr Mohammad. Enoxaparin can exacerbate an intra-cranial bleed. The inadequate record keeping meant that there was no contemporary account of the factors taken into consideration by the doctor or her supervising consultant in prescribing enoxaparin. Neither the Trust's initial serious incident investigation nor the consultant statement to the inquest mentioned the use of enoxaparin or the lack of clinical records justifying its use. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC). By way of background, Barts Health NHS Trust is one of the largest NHS trusts in the country, having been formed by the merger of Barts and the London NHS trust, Newham University Hospital NHS Trust and Whipps Cross University Hospital NHS Trust in April 2012. I note that the Chief Medical Officer at Barts Health NHS Trust wrote to you on 17 January 2023 setting out how it has addressed locally your five matters of concern in your prevention of future deaths report. The Department is content that the CQC took regulatory action when in May 2021, the CQC received whistleblowing concerns from staff working in imaging departments at Barts Health NHS Trust. These concerns included a wide range of issues including staffing, patient risk, processes, and leadership. To address these concerns CQC, alongside the Health and Safety Executive (HSE), carried out focused inspections and CQC had issued warning notices at the imaging departments of the Royal London Hospital and Whipps Cross Hospital in May 2021. A further inspection to review progress regarding improvement plans were carried out in September 2021. CQC found that the provider has complied with the warning notices issued previously and had made improvements to ensure that diagnostic imaging services had more oversight of staffing rotas and risk assessments. Given the historic concerns related to this core service Diagnostic Imaging at Barts Health NHS Trust remains on the risk register of the local team and is a priority for future inspection. Any inspection activity will also review the areas of concern identified in the last inspection report including processes for accessing high priority scans. The inspection report can be accessed on the CQC website at https://www.cqc.org.uk/location/R1H12/inspection-summary. CQC continues to monitor the above issues, alongside concerns identified in this Regulation 28 Report, and have regular engagement with Barts Health and other key stakeholders on this matter. I am writing to the Trust Chief Executive and the Chief Medical Officer seeking assurance that they do implement the changes to ensure patient safety is maintained both in preventing falls, but also ensuring staff have training to know when to act promptly should a head injury occur. I hope this response is helpful. Thank you for bringing these concerns to my attention. Best Wishes, MARIA CAULFIELD
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