Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0481, written 27 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Nov 2023 |
|---|---|
| Reference | 2023-0481 |
| Deceased | Amirah Khalifa |
| Coroner | Anita Bhardwaj |
| Coroner area | Liverpool and Wirral |
| Category | Alcohol, drug and medication related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Liverpool University Hospitals 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 NHS England & NHS Improvement (PFDs) 1 CORONER I am Anita BHARDWAJ, Area Coroner for the coroner area of Liverpool and Wirral 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 06 February 2023 I commenced an investigation into the death of Amirah KHALIFA aged 42. The investigation concluded at the end of the inquest on 24 November 2023. The conclusion of the inquest was that: Narrative Conclusion: Inappropriate and prolonged administration of steroids contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH once a day. She twice daily and then Amirah Khalifa was a 41 year old lady who had a complex medical history, including a presumed hepatocellular carcinoma for which she underwent a TACE (trans arterial chemoembolization) in 2016. On 31 August 2018 Amirah was admitted to the Royal Liverpool Hospital presenting with vomiting and right upper quadrant pain, a known complication after a TACE procedure. Various medications were prescribed but the pain was ongoing. On 11 September 2018, whilst still in hospital, Amirah was prescribed dexamethasone (a steroid), initially was then discharged from hospital. A discharge summary was sent to her General Practice (GP) requesting the steroid medication to be reviewed. When the steroids were prescribed there was no indication noted as to the length of the intended treatment course in the clinical notes or in the discharge letter issued by the hospital team. In April 2019 the steroids were noted as a repeat prescription in the GP records rather than an acute prescription. It is unclear upon what basis this was done. On 12 June 2019 Amirah was admitted to the Royal Liverpool University Hospital with dizzy spells. It was noted that her high blood pressure was poorly controlled. Her dexamethasone was continued in hospital and on discharge. A discharge summary was sent to her GP practice with the steroids to be continued. On 12 September 2019 Amirah was admitted to the Royal Liverpool hospital with similar symptoms. Her dexamethasone was continued again in hospital and on discharge. Throughout 2019-2022 Amirah had numerous consultations with various specialists in the Royal Liverpool University Hospital. On 29 December 2022 Amirah was admitted to the Royal Liverpool University Hospital feeling generally unwell and with leg pain. Treating medical professionals deemed that Amirah's case was complex and multiple organ systems were investigated and treated. Despite active treatment Amirah deteriorated and died on 31 January 2023. The post mortem examination found it was more likely than not Amirah died as a result of multiple organ failure caused by sepsis and intestinal haemorrhage as a result of long term steroid therapy. Throughout, on each discharge from hospital, a discharge letter was sent to Amirah’s GP and was generally to continue the Regulation 28 – After Inquest Document Template Updated 30/07/2021 dexamethasone. There were a number of failures relating to the care and treatment afforded to Amirah; through numerous appointments an incomplete medication history was taken and documented which did not include dexamethasone. Amirah had multiple complex conditions and was under the care of numerous specialists, many of whom clearly did not appreciate she was on steroids, and had been, for a lengthy period of time. Amirah was seen by numerous clinicians both in the hospital and in the community and at no stage was it questioned as to why she was still on the steroids, and why at the high dose she was on. Evidence has been heard that it was rare for a patient to be on these steroids at this dose for a lengthy period of time. Amirah presented with symptoms clearly suggestive of the possibility of complications of steroid use, namely uncontrollable blood pressure, diabetes, swelling and cognitive impairment. There was a failure to recognise these obvious presentations and the link between them and the long term steroid use. There was a failure to document in the clinical notes and / or in the discharge letter, the indication or length of the dexamethasone tablets. This failure prevented adequate instructions being provided to Amirah’s GP as to the intended length of the dexamethasone treatment and monitoring of the same. There was a failure for the GP to clarify the discharge with the hospital and to review the medication, this failure was exacerbated by the fact the prescription was changed to repeat from acute with no apparent reason. Overall, there was a catalogue of missed opportunities both in hospital as well as in the community to identify that Amirah remained unnecessarily on dexamethasone tablets despite multiple reviews as an inpatient and outpatient. Even when the ongoing prescription was identified, and Amirah was symptomatic of Cushing’s disease and steroid induced diabetes the correct action to wean treatment completely was not undertaken. It is a basic and fundamental expectation for a clinician in charge of a patient’s care to monitor and review prescribed medication, particularly acute medication such as steroids. There was a failure to do this for Amirah despite the fact that there were numerous opportunities to do so over a lengthy period of time. The accumulation of failures through the primary and secondary care services has led to a gross failure to provide basic medical attention to Amirah who was in a dependent position and had every reason to rely upon those who had management of her care and treatment to prescribe, monitor and review her medication. It is more likely than not the inappropriate and prolonged administration of steroids caused Amirah’s death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) The current SCR model does not appear to automatically flag drugs such as 1. steroids, which are known to have potentially fatal side effects if used for the long term without appropriate monitoring. It is understood that some drugs do have these flags, but that steroids do not. In addition, the SCR does not have a space recording for clinical indication for 2. initiation of the drugs, to aid a future prescriber to consider whether the drug is still clinically indicated. 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 January 22, 2024. I, the coroner, may extend the period. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 Royal Liverpool University Hospital Sandringham Medical Centre I have also sent it to 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 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 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 Dated: 27/11/2023 Anita BHARDWAJ Area Coroner for Liverpool and Wirral Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Anita Bhardwaj
Liverpool and Wirra Coroner’s Service
Gerad Majella Courthouse
Boundary Street
Liverpool
L5 2QD
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
24 January 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Amirah Khalifa who died
on 31 January 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 27
November 2023 concerning the death of Amirah Khalifa on 31 January 2023. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Amirah’s family and loved ones. NHS England are
keen to assure the family and the coroner that the concerns raised about Amirah’s
care have been listened to and reflected upon.
Your Report raises the concern that the current Summary Care Record (SCR) model
does not appear to automatically flag drugs such as steroids which may have
potentially fatal side effects when used long term. You also raised that the SCR does
not have space for recording the clinical indication for initiation of certain drugs to aid
future prescribers.
The National Care Records Service is the improved successor to the Summary Care
Record application (SCRa). The NCRS has been developed gradually over the last 4-
5 years, and as the NCRS product has matured, we have been migrating service users
across from SCRa to NCRS throughout 2023.
NCRS provide a quick, secure way to access national patient information to improve
clinical decision making and healthcare outcomes and it is free to use. It includes
additional features and services beyond the legacy SCRa product. The service is a
web-based application and can be accessed regardless of what IT system an
organisation is using. NCRS provides access to an ever-increasing number of centrally
provisioned national digital services that support the direct care of patients, including:
• Summary Care Records (SCR) - core and Additional Information
• National Record Locator Service (NRL) – pointers to and retrieval of data
held in local provider systems.
Details of long-term conditions, significant medical history and the reason for any
prescribed medication, should now be included by default for patients with an SCR,
unless they have previously told the NHS that they did not want this information to be
shared. For more information, and to illustrate the type of content included in an SCR,
an example SCR is available here: Additional Information in the SCR.
It is also relevant to the circumstances of Amirah’s care to note that NHS England has
commissioned the Royal Pharmaceutical Society (RPS) and the Royal College of
General Practitioners (RCGP) to develop tools and guidance to help primary care
healthcare professionals to improve issues concerning repeat prescribing. This follows
the publication in September 2021 of the Good for you, good for us, good for
everybody plan to reduce overprescribing in England and to ensure that patients get
the right treatment for their needs. The final toolkit is expected to be published in May
2024.
NHS England has also engaged with Cheshire and Merseyside Integrated Care Boad
on the circumstances of Amirah’s care raised in your Report and has been sighted on
the Serious Incident Review undertaken by Liverpool University Hospitals NHS
Foundation Trust (‘the Trust’). As part of the review, the Trust has identified clear
opportunities to prevent a similar incident occurring again and NHS England welcomes
the actions outlined in the Trust’s Improvement Plan. These include:
• Making the completion of the ‘changes to Medication’ part of Discharge
Summary documentation compulsory.
• Ensuring that the indication for long-term steroid treatment is included in drug
initiation, clerking documentation, discharge letters, medicines reconciliation
and primary care records.
• Making the medicines section of clinical letters compulsory.
NHS England would refer you to the Trust for any further information on their review
and action plan.
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,
Medical Director for Professional Leadership and Clinical Effectiveness
NHS England
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