Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0043, written 26 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jan 2024 |
|---|---|
| Reference | 2024-0043 |
| Deceased | James Atkinson |
| Coroner | Karen Dilks |
| Coroner area | Newcastle and North Tyneside |
| 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.
Newcastle and North Tyneside Ms Georgina Nolan SENIOR CORONER Civic Centre , Barras Bridge , Newcastle Upon Tyne , NE1 8QH REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Date: 26 January 2024 THIS REPORT IS BEING SENT TO: NHS England, Wellington House, 133-135 Waterloo Road, London, SE1 8UG Ministerial Correspondence and Public Enquiries Unit, Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU CORONER I am Karen Dilks, Assistant Coroner for Newcastle and North Tyneside 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. 1 2 http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 16 July 2020 I commenced an investigation into the death of James ATKINSON. The investigation concluded on 15 January 2024 at the end of the inquest. The conclusion of the inquest was (2) Anaphylaxis following peanut ingestion 3 (4) James Stuart Atkinson died on 10th July 2020 after eating a Chicken Tikka Masala pizza purchased from Dadyal Takeaway Restaurant in Newcastle upon Tyne via Deliveroo application. The pizza contained peanuts to which he was allergic. The Dadyal menu did not contain specific information in respect of peanuts or other allergens. James did not contact the takeaway to advise them of his allergy. He ate the pizza, following which he suffered an anaphylactic reaction. No Epi-pen was located and delayed his access to adrenaline until Paramedics attended. CIRCUMSTANCES OF THE DEATH James was 23 years old with a history of Asthma. In 2010 he was confirmed to have an allergy to nuts and in particular peanuts. He was prescribed an Epi-pen and antihistamines to manage his allergy. His Epi-pen was renewed only on his request, James last requested his Epi-pen in 2015. He attended 3 asthma reviews prior to his death. His allergy was not addressed during the reviews. There was no regular allergy review procedure provided locally or nationally. 4 On 10 July 2020 he ordered food for himself and flatmates from Dadyal Takeaway Restaurant. Their menu contained limited information as to the ingredients used in the dishes produced and no allergen information or allergen matrix. James ordered a Chicken Tikka Masala pizza. The presence of peanuts in both the dishes produced and in use in the kitchen was not referred to in the menu. James knew about his nut/peanut allergy. He did not contact Dadyal to advise of his allergy and was unaware that the Chicken Tikka Masala pizza ordered contained mixed nut powder comprising of up to 99 per cent peanuts. He suffered an allergic reaction shortly after consuming the pizza. He called an ambulance which arrived within four minutes of his call. His Epi-pen could not be located; missing an opportunity for an adrenaline injection prior to Paramedic arrival. Despite Paramedic and hospital care and treatment James died due to anaphylaxis resulting from peanut ingestion. 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. 5 6 The MATTERS OF CONCERN are as follows. – The evidence in this case unequivocally established that James was not under regular review for his allergy, risk of anaphylaxis and the benefits of automatic adrenalin injectors. The report of a systematic approach to improving anaphylaxis awareness and management. (attached) identifies the need for wider consideration of The risk of future deaths in the context of allergy/anaphylaxis remains in the absence of an appropriate structure to educate, review and manage those who are diagnosed allergies. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and The Rt Hon Victoria Atkins MP (Chair) 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 22 March 2024. I, the coroner, may extend the period. 7 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: family of James Stuart Atkinson, Food Standards Agency, NHS England (North East). I have also sent it to Deliveroo 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. 26 January 2024 9 HM Assistant Coroner for Newcastle and North Tyneside
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.
From the Rt Hon Andrew Stephenson CBE MP Minister of State for Health and Social Care 39 Victoria Street London SW1H 0EU Karen Dilks Assistant Coroner for Newcastle and North Tyneside Civic Centre Barras Bridge Newcastle Upon Tyne NE1 8QH Dear Ms Dilks, 19 April 2024 Thank you for a copy of your Regulation 28 report to prevent future deaths, dated 26 January 2024, into the circumstances surrounding the death of James Atkinson. I am replying as Minister with responsibility for long-term conditions, including allergies. Firstly, I would like to say how saddened I was to read of the circumstances of James’ death, and I offer my sincere condolences to his family and loved ones. His loss at such a young age must be extremely distressing for them 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 and I am thankful for the extension you have granted. In preparing this response, Departmental officials have made enquiries with NHS England, to which you also issued your report. I am assured that your concerns have been carefully considered and I hope their response to you is helpful. I noted the extensive work of NHS England’s Clinical Reference Group in particular, including the current review of the Specialist Allergy Service Specification, as well as the learnings and improvements implemented at the relevant practice and integrated care board. My response will focus on the matters of concern relating to the need to educate, review and manage those who are diagnosed with allergies. Under the GP contract, GP practices are required to provide a set of core services, termed essential services. They include the identification and management of illnesses, providing health advice and referral to other services during core hours, which are 8.00am–6.30pm Monday to Friday, excluding bank holidays. There is an expectation that GP practices review patient medication on a regular basis as part of these essential services and we expect commissioners to take action if services are not meeting the reasonable needs of their patients. Medication reviews are, of course, particularly important for medicines provided on repeat prescriptions to confirm that the patient is taking their medicines as directed and check that medicines are still needed, effective and tolerated. The General Medical Council (GMC), the independent regulator of all medical doctors practising in the UK, has issued ethical guidance for doctors on reviewing patients’ medication, Good practice in prescribing and managing medicines and devices. The guidance is clear that doctors have a duty to ensure they are prescribing and managing patients’ medicines appropriately, and that doctors must ensure that suitable arrangements are in place for monitoring, follow up and review. The guidance can be found at www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-practice-in- prescribing-and-managing-medicines-and-devices/reviewing-medicines. Information is contained in the British National Formulary (BNF) that patients who are at risk for or have a history of serious allergic emergencies carry two adrenaline auto-injector devices (AAIs) at all times; on the importance of training patients and carers in the use of the particular AAI prescribed, as well as other advice aimed at patients and carers. The BNF is a joint publication of the British Medical Association and the Royal Pharmaceutical Society, and is accessible from the National Institute for Heath and Care Excellence’s (NICE) website, with the relevant information available at https://bnf.nice.org.uk/drugs/adrenaline-epinephrine/. Prescribers are expected to refer to information within the BNF to help inform prescribing decisions made with individual patients and carers. This expectation is also set out in Good practice in prescribing and managing medicines and devices, within the section entitled: ‘keeping up to date and prescribing safely’ which can be found at https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors/good- practice-in-prescribing-and-managing-medicines-and-devices/keeping-up-to-date-and- prescribing-safely. As you will aware, NICE has developed evidence-based guidance to support clinicians in managing allergy and related disorders. Guidance is routinely subjected to an evidence surveillance exercise to establish whether an update is available. However, guidance will be reviewed and updated at any time if important new evidence comes to light. NICE has published a clinical guideline, Anaphylaxis: assessment and referral after emergency treatment (CG134), and a quality standard on anaphylaxis (QS119). Both this guideline and quality standard cover care after emergency treatment for suspected anaphylaxis, including assessment and referral to specialist allergy services. That is, they begin at the point in the clinical pathway immediately after a health professional has started to manage a suspected anaphylactic reaction. It is not clear from your report whether James had ever experienced an anaphylactic reaction before the one that caused his death. It is, therefore, unclear whether either CG134 or QS119 would have been directly relevant to the issues that contributed to his death. In June 2023, the Medicines and Healthcare products Regulatory Agency (MHRA), with the support of allergy awareness advocates, launched a safety campaign to raise awareness of anaphylaxis and provide advice on the use of AAIs. As part of this campaign, a toolkit of resources was made available for health and social care professionals to support the safe and effective use of AAIs. Health and social care professionals were asked to use the materials to inform patients and caregivers what to do if they suspect anaphylaxis and how to use AAIs. Details of the campaign and the resources can be found at https://www.gov.uk/drug-safety-update/adrenaline-auto- injectors-aais-new-guidance-and-resources-for-safe-use. Finally, in June 2023, the British Society for Allergy & Clinical Immunology (BSACI) published Adrenaline auto-injector prescription for patients at risk of anaphylaxis: BSACI guidance for primary care. The guidance was developed to address key primary care clinical questions informed by current practice and known gaps in care from reported fatalities. It is intended to act as a resource and signpost to materials for primary care workers. The guidance is intended to assist in decision-making during consultations, especially around risk assessment, need for referral and prescription of AAIs, by simplifying the understanding and practice of prescribing for health professionals. This guidance can be found at https://www.bsaci.org/guidelines/primary-care- guidelines/adrenaline-auto-injector-prescription-for-patients-at-risk-of-anaphylaxis-bsaci- guidance-for-primary-care/. I hope this response is helpful. Thank you once again for bringing these matters to my attention. ANDREW STEPHENSON MP
Karen Dilks
Lord Mayor’s Suite
Civic Centre
Barras Bridge
Newcastle Upon Tyne
NE1 8QH
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
29 April 2024
Re: Regulation 28 Report to Prevent Future Deaths – James Atkinson who died
on 10 July 2020.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26
January 2024 concerning the death of James Atkinson on 10 July 2020. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to James’ family and loved ones. NHS England are keen to
assure the family and the coroner that the concerns raised about James’ have been
listened to and reflected upon.
NHS England has a Clinical Reference Group (CRG) that provides clinical advice and
leadership for both Specialised Immunology and Specialised Allergy services. The
membership includes clinicians, commissioners, public health experts and Patient and
Public Voice members. They use their combined knowledge and expertise to advise
NHS England on the optimal arrangements for the commissioning of specialised
for services delivering
services. This
specialised care to patients with allergies in the form of national service specifications
and policies. The CRG commenced a review of the current published Specialist Allergy
Service Specification in May 2023, which is expected to be complete by Summer 2024.
includes developing national standards
This particular case highlights the need for supporting young people as they transition
from children to adult services. The updated service specification will strengthen the
requirement for providers of specialist allergy services to plan, organise and implement
transition support and care, for example by holding joint annual review meetings with
the child/young person, their family/carers, and the children’s or adult service. The aim
is to ensure that young people are equal partners in planning and decision making and
that their preferences and wishes are central throughout transition and transfer. The
specification work will include reviewing existing requirements in relation to self-care
and the provision of service user/carer information and the updated specification is
also likely to set out the requirement for specialist centres to develop documented
personal management plans for patients with allergic conditions, with guidance for
ongoing primary or specialist care.
The Executive Area Director (Tees Valley and Central) within the North East and North
Cumbria Integrated Care Board (NENC ICB) have also reviewed the concerns raised
in your report. They have advised that learnings were taken, and changes and
improvements have been made by the Practice involved in this matter. The learning
will be shared with other practices across NENC ICB to maximise learning and
improvement opportunities for the improvement of patient safety.
The following links to guidance were also shared by NHS England’s North East and
Yorkshire Regional Chief Pharmacist to reinforce guidance and learning:
• Adrenaline auto-injectors (AAIs): new guidance and resources for safe use -
GOV.UK (www.gov.uk)
• EpiPen®: Guidelines For Healthcare Professionals | EpiPen®
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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