Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0411, written 22 Dec 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Dec 2022 |
|---|---|
| Reference | 2022-0411 |
| Deceased | Allah Ismail |
| Coroner | Nigel Meadows |
| Coroner area | Manchester City |
| Category | Other 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 FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
– Medical Director
Healthcare Quality Improvement Partnership Ltd (HQIP)
27A Harley Place
45 Moorfields
London
EC2Y 9AE
•
•
President of the British Thoracic Society
17 Doughty Street,
London
WC1N 2PL
Copied for interest to:
• Family members of the deceased
• MFT NHS Trust
1 CORONER
I am: Senior Coroner Nigel Meadows
Senior Coroner for Manchester City Area
HM Coroner’s Court and Office
Exchange Floor
The Royal Exchange Building
Cross Street
Manchester
M2 7EF
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 the 30th July 2019 I commenced an investigation into the death of. The investigation
concluded on the 15th December 2022.
The Narrative Conclusion of the inquest was: The deceased died as a consequence of
serious traumatic injuries she sustained in an accidental fall in Pakistan at about 02:30 hours
1
on the 9 July 2019 which were not all initially diagnosed in combination with other serious
comorbid conditions. She was not correctly assessed as being unfit to fly and during her
flight back to United Kingdom on 12 July 2019 her condition significantly deteriorated. On
arrival she was admitted to hospital in Manchester. Despite ongoing medical management
her condition suddenly deteriorated on 25 July, and she died following day. She probably
would not have survived even if aspects of her treatment had been different.
Circumstances of the death
1. The deceased suffered from suffered from several serious chronic comorbid
conditions. At about 02.30 hours on 9 July 2019 while staying in a property in Lahore,
Pakistan when mobilising to go to the toilet she fell from a high bed onto a hard tiled
floor and landed heavily. She was taken to the National hospital in Lahore where she
was assessed as only having suffered a fractured clavicle. She was not diagnosed
with also suffering from several fractured ribs which amounted to flail chest as well as
a subdural haematoma. She was discharged from hospital on 10 July 2019 with a
recording oxygen saturation level of 88% which should have precluded her from
flying without supplemental oxygen being provided. She flew back to Manchester in
the United Kingdom on 12 July 2019, but during the flight she suffered from serious
cardiac and respiratory distress. On landing she was transferred to an ambulance
and immediately taken to Wythenshawe Hospital in Manchester.
2. Shortly after admission she was diagnosed suffering from flail chest and a subdural
haemorrhage in addition to a chest infection. She was treated with antibiotics and her
usual heart medication was omitted. Her condition steadily improved and on 15 July
2019 she was referred to Huddersfield hospital in Yorkshire in order for her to be
transferred for continuing rehabilitation and medical management. A bed was not
initially available and on 19 July 2019 she was unable to be moved because her
potassium levels high and her kidney function had deteriorated. On 20 July 2019 her
condition had deteriorated, and she had developed the degree of fluid overload and
was recommenced on a diuretic medication.
3. By 22 July 2019 she was noted to have had fluctuating drowsiness and an element of
delirium and having little no oral intake. The administration of oxygen during her
admission was appropriate, but on occasions not correctly documented. On the
afternoon of 25 July 2019, she suffered a serious deterioration when, despite
appropriate medical management and treatment, her condition deteriorated, and she
died on 26 July 2019. Different medical treatment would have more than minimally
increased the chances of survival, although, on the balance of probabilities, it would
not have altered the eventual outcome.
4. The expert respiratory medicine witnesses in the case agreed that it was best
practice for target oxygen saturations to be documented and for oxygen to be titrated
to achieve these levels but in their experience, this is often poorly done on non-
specialist wards and what happened Wythenshawe hospital was not uncommon. It
was recognised that was certainly best practice, but the local MFT Trust guidelines
are to prescribe oxygen. There was a national problem with oxygen prescribing which
had been recognised by audits undertaken by the BTS.
5. There are no NICE guidelines, but the BTS guidance are clear. An audit that took
place in 2015 indicated that Wythenshawe hospital was actually doing better than the
rest of the country in complying with the guidance. There was a difference between a
direction for oxygen being written in the clinical records as opposed to being
2
recorded on a drug chart. In practical terms it was simply implementing the guidelines
at the coalface which was the problem. It was not clear whether a re-audit being
undertaken but there was a necessity for wider education of all physicians in the
prescribing of oxygen within MFT NHS trust and more widely in the country.
6. Following the last BTS audit MFT took steps to address any patient safety issues that
come from not prescribing oxygen and that was through the introduction of oxygen
variance forms and there is ongoing programme of education for all doctors as they
begin work at MFT. There still appears to be national inconsistency in addition to the
use of both paper and electronic records with the added complication of a move
towards using electronic records only. Patients are at risk of harm, serious harm, or
death as a consequence of over oxygenation or under oxygenation. There was no
evidence in the medical literature for the use of Bi level Ventilation for a patient with
flail chest.
Important Explanatory Notes:
The BTS is a registered charity and not a governing body. The aim of the BTS audits are to
support members to identify and improve standards of care for people with respiratory
disease. The request for the BTS to undertake a further review and audit would be costly for
this charity to conduct on a national scale.
The BTS may be planning to update their 2017 guideline for oxygen use in adults in
healthcare and emergency settings. The Healthcare Quality Improvement Partnership
(HQIP), is the arm’s length, centrally funded, government body responsible for several
national healthcare quality improvement programmes. From a funding, logistics and
resources perspective, HQIP is likely to be better placed to consider the feasibility of a
national audit programme.
Therefore, and again pragmatically, it may be more appropriate for any national audit to take
place following the introduction of the updated guideline, with appropriate funding in place,
potentially from HQIP. It would be important for there to be co-ordination between the HQIP
and the BTS.
The BTS provides open access to its’ audit tools. This allows hospital trusts to conduct
recurrent audits for assurance against the agreed standards of care and also compare their
data with the national picture as it appeared at the time of the previous audit period. The last
BTS National Emergency Oxygen Audit was run in 2015. Consequently, there is an
opportunity for HQIP to encourage Trusts to use the BTS audit tools to evaluate its data and
performance now, pending a future national audit.
5 CORONER’S CONCERNS
The MATTERS OF CONCERN are as follows:
1. That the HQIP should consider undertaking in liaison with the BTS a further review
and audit in relation to delivering a recurrent national audit of emergency oxygen.
This update will also be able to use learning from recent clinical practice (including
the Covid pandemic) and the developments in treatment.
3
2. Formulate any new guidelines and recommend any necessary changes to try and
improve national practice.
3. The HQIP could encourage all NHS Trusts to use the BTS audit tools to evaluate its
data and performance now, pending a future national audit.
4. The BTS have already issued guidance for passengers travelling with respiratory
conditions; namely, the BTS Clinical Statement on air travel for passengers with
respiratory disease (https://thorax.bmj.com/content/77/4/329). However, this
guidance does not cover trauma, as in this case. Whether or not guidance would be
appropriate to issue to determine whether or not a person was fit to fly from a
respiratory perspective in the context of trauma – Consideration should be given to
formulating such guidance which can then be circulated more widely including to the
airline industry
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 the 1st March 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 Interested Persons. I have also
sent it to organisations who may find it useful or of interest.
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 DATE: 22nd December 2022 Mr Nigel Meadows
HM Senior Coroner
Manchester City Area
Signed:
4
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.
Mr Nigel Meadows HM Senior Coroner, Manchester City Area HM Coroner’s Court and Office Exchange Floor The Royal Exchange Building Cross Street Manchester M2 7EF 29 March 2023 Dear Mr Meadows, By email Coroner’s Report to Prevent Future deaths: Regulation 28 Thank you for the copy of your email of 22 December 2022 to Professor Keenan and the attached Regulation 28 Report to prevent future deaths. HQIP and BTS colleagues have had the opportunity to discuss this report and have notified NHS England concerning your letter. We are writing jointly to provide our response. We would like to acknowledge that this Report was prepared as a result of the sad death of Mrs Ismail. We would like to send our condolences to Mrs Ismail’s family. In relation to the specific points mentioned in the report, we would like to provide the following information: 1. That the HQIP should consider undertaking in liaison with the BTS a further review and audit in relation to delivering a recurrent national audit of emergency oxygen. This update will also be able to use learning from recent clinical practice (including the Covid pandemic) and the developments in treatment. 2. Formulate any new guidelines and recommend any necessary changes to try and improve national practice. HQIP commission, manage and develop the National Clinical audit and patients outcome programme (NCAPOP) under contract from and on behalf of NHS England and the Welsh Government. All clinical topics in the Programme are selected by NHS England. At present, none of the currently commissioned NCAPOP topics cover the prescription of emergency oxygen. Since the BTS publication of the first guideline on emergency oxygen use in 2008 and the subsequent update in 2017, BTS has conducted a programme of audit and provided tools to support education and implementation of the guideline recommendations. This information is freely available on our website (https://www.brit-thoracic.org.uk/quality-improvement/clinical- resources/oxygen/ ). The BTS Standards of Care Committee has recently accepted a proposal to develop revised guidance on target oxygen saturations in the light of new evidence published since the last guideline was issued. Publication of updated guidance would provide an opportunity for further dissemination and education in relation to best practice as well as the development of Quality Standards for the administration of emergency oxygen which would provide standards against which any future audit could be conducted. 3. The HQIP could encourage all NHS Trusts to use the BTS audit tools to evaluate its data and performance now, pending a future national audit. A major thrust of the work that HQIP does is the drive to disseminate the findings from the NCAPOP and taking that forward into actually implementing the recommendations so that we improve the quality of care that we offer to patients. NHS England are a party to this work and they, with us and partner organisations such as the Royal Colleges and the specialist societies are keen that audit tools become embedded. The BTS Quality Improvement Committee has also discussed the need for quality improvement in this area to ensure that improvement in oxygen prescription and administration is made before any future national audit. The BTS Audit system has the facility for sites to audit their own practice at any time, outside the periods of any national audit. This “local audit” facility allows them to collect data for quality improvement purposes and communications about this are regularly publicised to BTS audit users. BTS will continue to highlight the importance of the need for oxygen prescription and monitoring, and encourage use of its existing audit tools to support local quality improvement in this area pending any updated guideline recommendations and associated education and dissemination activities. In future. should BTS initiate a full national audit round, HQIP has confirmed that it would support an application for inclusion in the Quality Accounts Audit list. These are audits mandated as part of the standing contract with Trusts to participate and report in their annual Quality Account. 4. The BTS have already issued guidance for passengers travelling with respiratory conditions; namely, the BTS Clinical Statement on air travel for passengers with respiratory disease (https://thorax.bmj.com/content/77/4/329). However, this guidance does not cover trauma, as in this case. Whether or not guidance would be appropriate to issue to determine whether or not a person was fit to fly from a respiratory perspective in the context of trauma – Consideration should be given to formulating such guidance which can then be circulated more widely including to the airline industry. We note the reference to the BTS Clinical Statement on air travel for passengers with respiratory disease. As outlined above this document provides guidance for clinicians who advise those with respiratory disease in planning air travel. This document does not include specific guidance for patients who have suffered trauma or surgical interventions. We note that there is guidance for health care professionals in relation to surgery available through the CAA: Surgical conditions | Civil Aviation Authority (caa.co.uk) We suggest that it would seem appropriate that this gap in guidance in relation to trauma patients would best be addressed by the CAA in any further revision of its guidance. We hope this response is helpful and provides assurance that the British Thoracic Society will continue its work to inform, educate and support respiratory health care professionals to support safe and appropriate oxygen administration within the hospital setting, and where appropriate will work with HQIP and other colleagues in this important area. Yours sincerely, BTS President HQIP BTS/HQIP March 2023 2
NIGEL MEADOWS – HM SENIOR CORONER FOR AREA OF MANCHESTER CITY INVESTIGATION INTO THE DEATH OF MRS ALLAH RAKHI ISMAIL CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT OTHER DEATHS PURSUANT TO REGULATIONS 28 & 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Introduction The UK Civil Aviation Authority (‘CAA’) would first like to express its sincere condolences to the family and friends of Mrs Ismail. The CAA is a public corporation, established by Parliament in 1972 as an independent specialist aviation regulator. The CAA works so that: • • • • the aviation industry meets the highest safety standards, consumers have choice, value for money, are protected and treated fairly when they fly, through efficient use of airspace, the environmental impact of aviation on local communities is effectively managed and CO2 emissions are reduced, the aviation industry manages security risks effectively. The CAA has carefully considered the Regulation 28 Report to prevent future deaths issued by the Senior Coroner for Manchester City (‘the Report’), including the following recommendation that is considered to be relevant to its role and functions: The British Thoracic Society (‘BTS’) have already issued guidance for passengers travelling with respiratory conditions; namely, the BTS Clinical Statement on air travel for passengers with respiratory disease (https://thorax.bmj.com/content/77/4/329). However, this guidance does not cover trauma, as in this case. Whether or not guidance would be appropriate to issue to determine whether or not a person was fit to fly from a respiratory perspective in the context of trauma – Consideration should be given to formulating such guidance which can then be circulated more widely including to the airline industry. The CAA was not an Interested Person at this inquest. As such, it did not have access to the evidence. When preparing this response, with a view to implementing future action, the CAA has relied on the information contained in the Report, together with the response disclosed by the BTS dated 29 March 2023 and information relating to physiological factors of relevance to flight safety that is already published by the International Civil Aviation Organisation (‘ICAO’), and by the CAA itself. Next Steps Practical guidance on aviation medicine is contained in the ICAO published Manual of Civil Aviation Medicine1. The main purpose of this manual is to assist, and guide designated medical examiners and licensing authorities in decisions relating to the medical fitness of licence applicants. The manual is also viewed as a useful supplement to properly supervised theoretical and practical post-graduate training in aviation medicine. Chapter 1 of the Manual - Physiological Factors of Relevance to Flight Safety, contains industry guidance that is directly relevant to the body’s ability to tolerate reduced barometric pressure, which would be expected to be encountered whilst in flight. The response to the Report, disclosed by the BTS dated 29 March 2023, refers to guidance that is also published on the CAA’s website for air passengers who have experienced trauma or undergone surgery. The web page link: this guidance can be https://www.caa.co.uk/passengers/before-you-fly/am-i-fit-to-fly/guidance-for-health- professionals/surgical-conditions/. found at following the for The CAA would expect operators in the aviation industry to be aware of the ICAO Manual of Civil Aviation Medicine and the CAA’s published guidance. The CAA has now amended its own guidance to include new information that is relevant to passenger fitness to fly, which reflects the recommendation in the Report. The following entry is included in the guidance published on the CAA’s website under the section entitled: ‘Surgical Conditions - Trauma’: “Passengers who have experienced traumatic injuries within 7 days prior to travel, including from falls or accidents of any nature, should contact their airline to determine their suitability to travel. This is particularly important with injuries affecting the chest, as these may cause cardio-respiratory decompensation at altitude.” The CAA will also discuss the content of the Report at the next UK Fitness to Fly Forum meeting on 5th September 2023. The Forum draws together considerable experience of those working in aviation medicine to highlight any new or developing medical issues which may act to limit passenger accessibility to air travel. This Forum is attended by medical representatives from several of the UK’s largest airlines and is intended to share best practice across the aviation industry and the NHS. MBChB BSc (Hons) MSc MRCP (UK) MRCGP DAvMed PgCertROM Consultant in Aviation and Space Medicine Medical Assessor UK Civil Aviation Authority 31 May 2023 1 Manual of Civil Aviation Medicine (Doc 8984), 3rd Edition, 2012.
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