Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0323, written 7 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Sep 2023 |
|---|---|
| Reference | 2023-0323 |
| Deceased | Graham Smith |
| Coroner | Simon Brenchley |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Birmingham NHS Foundation 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.
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
THE CHIEF EXECUTIVE, NHS ENGLAND
CORONER
I am Simon Brenchley Assistant Coroner for Birmingham and Solihull
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.
INVESTIGATION and INQUEST
On 13 March 2023 I commenced an investigation into the death of Graham Thomas John SMITH.
The investigation concluded at the end of the inquest on 24th August 2023. The conclusion of the
inquest was;
Died from natural causes likely contributed to by a combination of the delay in him being
prescribed his normal medication for the condition Myasthenia Gravis from which he suffered as
well as him being prescribed on admission a dose of an antibiotic medication for sepsis that was
contraindicated in his case.
The medical cause of his death was:
1(a) Respiratory Failure. Chest Infection
1(b) Myasthenia Gravis
II Biliary Sepsis. Type 2 Diabetes
CIRCUMSTANCES OF THE DEATH
Graham Smith suffered from Myasthenia Gravis, a rare long-term condition that causes
muscle weakness and for which he was prescribed Pyridostigmine by his GP. On 1st
March 2023 he was admitted to the Emergency Department of the Queen Elizabeth
Hospital in Birmingham with suspected biliary sepsis/ascending cholangitis due to an
obstructing bile gall stone as well as a bilateral basal consolidation which was revealed by
a chest x ray.
Whilst in the ED, he was initially prescribed Tazocin for treatment of the sepsis but was
then given a dose of Gentamicin which is in fact contraindicated in patients suffering from
Myasthenia Gravis. He was not prescribed his normal Pyridostigmine.
On 2nd March he was transferred to a Liver ward for further treatment and arrangements
were made for him to undergo an Endoscopic Retrograde Cholangiopancreatography
Procedure ('ERCP') which could not be done until 3rd March.
In the early hours of 3rd March he deteriorated suddenly and was seen by the Critical Care
Outreach Team who noted that he had not been prescribed his normal medication since
admission and that he had received a dose of the Gentamicin. He was found to be
suffering from a myasthenic crisis causing respiratory failure.
He was restarted on the Pyridostigmine and treatment and management of his sepsis
continued on ICU. Following a successful ERCP procedure later on 3rd March, his
inflammatory markers were improving and his cholangitis was noted to be resolving over
the next few days. However, he continued to have multi organ dysfunction with increasing
respiratory failure and following a further significant deterioration passed away on 7th
March.
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 will 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. During the course of the inquest I heard evidence from the author of a Serious
Investigation Report commissioned by the Trust (University Hospitals Birmingham)
that the errors with regard to medication were, in part, due to a lack of awareness
on the part of clinicians within the Trust as to the seriousness of Myasthenia Gravis
as well as the interaction between Gentamicin and this condition.
2. I also heard evidence from the author of the SI report about a comprehensive action
plan that is being put in place to raise awareness within the Trust including the
development and issue of a Trust wide patient safety notice in relation to Antibiotic
Prescribing in patients with Myasthenia Gravis.
3. However, given the apparent lack of awareness about Myasthenia Gravis amongst
clinicians within UHB, a large hospital trust in a significant metropolitan area, I am
concerned that there is a risk that a similar lack of awareness could persist amongst
clinicians in other areas of the country and that consideration should be given to
raising awareness more widely.
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 by
3 November 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.
COPIES and PUBLICATION
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I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
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• University Hospitals Birmingham NHS Foundation Trust
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 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.
7 September 2023
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Signature:
Simon Brenchley
Assistant Coroner for Birmingham and Solihull
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.
Simon Brenchley
Birmingham and Solihull Coroner’s Court
50 Newton Street
Birmingham
B4 6NE
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
25 October 2023
Re: Regulation 28 Report to Prevent Future Deaths – Graham Thomas John
Smith who died on 7 March 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7
September 2023 concerning the death of Graham Thomas John Smith on 7 March
2023. In advance of responding to the specific concerns raised in your Report, I would
like to express my deep condolences to Graham’s family and loved ones. NHS
England are keen to assure the family and the coroner that the concerns raised about
Graham’s care have been listened to and reflected upon.
In your Report you raised the concern that there is a risk that there could be a national
lack of awareness from clinicians of Myasthenia Gravis and its contraindications. This
was because the Serious Investigation Report commissioned by University Hospitals
Birmingham Trust, and which you heard at inquest, raised that there was a lack of
awareness within the Trust which, as you say, is a large Trust in a metropolitan area.
The antibiotic, Gentamicin, which was administered to Graham while he was in the
Emergency Department is clearly contraindicated for patients with Myasthenia Gravis
(MG) in the British National Formulary (BNF). The BNF is a joint publication of the
British Medical Association (BMA) and the Royal Pharmaceutical Society with the
purpose of providing prescribers, pharmacists, and other healthcare professionals with
sound up-to-date information about the use of medicines. The Summary of Product
Characteristics within the electronic medicines compendium (emc) also makes clear
the risks associated with Gentamicin and other antibiotics in patients with MG. The
emc contains up to date, easily accessible information about medicines licensed for
use in the UK. Both the BNF and the emc are well-known and trusted resources for
medical professionals. My national Patient Safety colleagues have also advised that
many Trust prescribing guidelines and/or patient information leaflets do raise the risk
of Myasthenia Gravis contraindications, and I include some examples here: Policies
and Procedures Trust Framework (gloshospitals.nhs.uk), PI_7-Aminoglycoside-
antibiotic-therapy.pdf (royalpapworth.nhs.uk).
The issue of patients not receiving their normal medications (in this case,
Pyridostigmine) while in an emergency hospital setting falls into the omitted and
delayed medications category. This is an issue that specialist pharmacy service
colleagues are currently in the process of developing new guidance to address and
NHS England can undertake to update the coroner once this new guidance has been
published. NHS England is also aware that the Royal College of Emergency Medicine
(RCEM) are preparing a Safety Flash to raise awareness of delivering time critical and
important medications when patients are in Emergency Departments for long periods.
My regional colleagues in the Midlands are also in the process of engaging with
Birmingham University Hospitals Trust and Birmingham and Solihull Integrated Care
Board on the concerns raised in your Report and what local actions have been
identified and will keep national NHS England colleagues updated on the status of
this. You may also wish to contact the Trust directly.
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 the 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 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
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