Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0403, written 13 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Oct 2023 |
|---|---|
| Reference | 2023-0403 |
| Deceased | Peter Carr |
| Coroner | Peter Straker |
| Coroner area | London (North) |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
Regulation 28: Prevention of Future Deaths report Peter Carr (died 21/09/21) THIS REPORT IS BEING SENT TO: Department of Health and Social Care 39 Victoria Street London, SW1H 0EU 1 CORONER I am: Dr. P. H. Straker, Assistant Coroner for North London Barnet Coroner’s Court 29 Wood Street, London EN5 4BE 2 CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3 INVESTIGATION and INQUEST On 5th October 2021 I commenced an investigation into the death of Peter Carr. The investigation concluded at the end of the inquest held on the 9th,10th and 11th of October 2023. The conclusion of the inquest was a short narrative conclusion; Peter Carr died from a recognised complication of necessarily prescribed medication. 4 CIRCUMSTANCES OF THE DEATH On the 25th of August Mr. Carr developed a rash. By the 31st most of his skin was red so he presented to the North Middlesex Hospital A&E where he was admitted by the medical team. He also had neutropenia and lymphadenopathy.The admitting doctor prescribed tazocin, a rare side effect of which is Stephens-Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN.) The North Middlesex outsources dermatology. Mr. Carr first saw a dermatologist 3 days after admission at which point there was no sign of SJS / TEN. Nevertheless skin biopsy - something every consultant dermatologist can do - was deemed necessary but the attendant dermatologist, who could have done this, did not becaue the company's process is to ask a plastic surgeon to biopsy. It took until the 8th for the biopsy to be taken. There was no dermatological oversight of Mr Carr's skin in the intervening time. The biopsy found evidence of drug reaction consistent with SJS. An optimum dermatology service was described by our expert as patients being seen by a consultant dermatologist and biopsied if required within 24 hours of presentation, and then watched like a hawk on a daily basis. Had this happened the emergence of SJS may have been recognised and prompted withdrawal of the culprit medication. That this level of dermatological support was not available denied Mr. Carr 'a role of the dice' - a chance of survival. CORONER’S CONCERNS 5 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. That patients who contact medical services with acute, severe, skin conditions as primary presentations, or as a component of a complex presentation, may not have consultant dermatology input and biopsy within 24 hours and ongoing consultant dermatology oversight for the duration of an inpatient stay. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that your organisation has 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 29 th December 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 following. ● The Family. ● Omnes Healthcare. ● The North Middlesex University Hospital. ● University College London Hospital. ● 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 13th October 2023. Assistant Coroner. Dr. Peter Straker
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 The Rt Hon. Andrew Stephenson CBE MP Minister of State for Health 39 Victoria Street London SW1H 0EU Dr. P. H. Straker Assistant Coroner for North London Barnet Coroner’s Court 29 Wood Street London EN5 4BE 8 May 2024 Dear Mr Straker, Thank you for your Regulation 28 report to prevent future deaths dated 13 October 2023 about the death of Peter Carr. I am replying as Minister with responsibility for medicines. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Carr’s death and I offer my sincere condolences to his 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. I would like to assure you that the department is mindful of the statutory responsibilities in relation to prevention of future deaths reports and we are prioritising responses as a matter of urgency. The report raises concerns, “that patients who contact medical services with acute, severe, skin conditions as primary presentations, or as a component of a complex presentation may not have consultant dermatology input and biopsy within 24 hours and ongoing consultant dermatology oversight for the duration of an inpatient stay”. In preparing this response, Departmental officials have made enquiries with NHS England, the Care Quality Commission (CQC), Medicines & Healthcare products Regulatory Agency (MHRA) and I share their findings and actions taken to address your concerns. It is understood that Stevens-Johnson (SJS) syndrome is a recognised but rare complication following the administration of some medications, and patients often present in the emergency department and are cared for by admitting physicians. It requires rapid diagnosis and specialist referral for onward management of the condition. We enquired about the information provided with the medication from MHRA. They advise that the product information for Tazocin highlights the risk of severe cutaneous adverse reactions, including SJS and that patients developing skin 1 reactions should be closely monitored. There are warnings in the prescribing information and the patient leaflet which advises that patients should see a doctor immediately if they experience any of the listed potentially serious side effects of Tazocin. I understand that there can be difficulties in the diagnosis and management of the patient pathway which is complex as it covers both a general and specialised pathway. The NHS England service specification for specialised dermatology highlights the importance of early referral to treat SJS and we recognise that a specialist service is required for this group of patients. NHS England are undertaking work to develop a pathway, and intends to undertake a provider selection exercise in due course. More locally, I understand that the Trust has improved the accessibility of Dermatology Services and introduced a new inpatient protocol agreed with the provider, Omnes, which ensures that inpatients requiring Dermatology review are seen within 1 working day. There is an escalation plan in place if reviews do not occur in line with agreed timescales. The Trust continues to monitor the provider for quality and performance against the protocol. They are also identifying opportunities to bring the outpatient service back onto the Trust site, which in turn will assist timely inpatient reviews. To ensure that key messages permeate down to staff at the workplace, the Trust is cascading the inpatient protocol via their Medical Director’s bulletin, the induction pack for all medical staff and their internal intranet page. They have also updated the information on accessing Dermatology services both in and out of hours. Alongside this, sessions have also been set up to educate the staff on recognising early signs of emergency dermatological conditions, including SJS and Toxic Epidermal Necrolysis (TEN). Further, the Trust is exploring with Omnes, provision of a biopsy pack for dermatologists to undertake skin biopsies when required for inpatients. It is equally important to apply learning and improvements to the wider system and I note that the Trust is conducting a review of all other services outsourced to third parties. Their aim is to ensure that the inpatient review process and accessing the out of hours service is clear. This information will be communicated to all staff who require it and be made available on the Trust intranet. I realise that responses can form an important part of the process of family and friends coming to terms with what happened to their loved one and the recognition that steps have been taken to prevent it happening in the future. I have been informed that the Trust has also corresponded with the family around the steps taken to improve procesess and embed the learning throughout their system. I believe it is vital that we continue to improve patient outcomes and implement learning in the NHS which contributes to saving more lives. I have been assured that CQC contacted the Trust following this report and will continue to monitor the Trust to ensure safe standards of care are maintained through ongoing surveillance and engagement meetings. I thank you once again for bringing these concerns to my attention. THE RT HON ANDREW STEPHENSON CBE MP MINISTER OF STATE
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