Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2024-0281, written 4 Aug 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Aug 2022 |
|---|---|
| Reference | 2024-0281 |
| Deceased | Malcolm Garrett |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| 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: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Health and Social Care 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 30th September 2021 I commenced an investigation into the death of Malcolm John Garrett. The investigation concluded on the 16th June 2022 and the conclusion was one of Narrative: Died from Covid-19 acquired whilst an inpatient contributed to by the complications of a lung transplant. The medical cause of death was 1a) Covid pneumonitis and pseudomonas aeruginosa bronchopneumonia; II) Chronic immunosuppression (lung transplant 2013), chronic allograft dysfunction/bronchiolitis obliterans, non-traumatic thoracic vertebra wedge fracture, ischaemic heart disease, chronic kidney disease. 4 CIRCUMSTANCES OF THE DEATH Malcolm John Garrett had a bilateral lung transplant in 2013. He was placed on long term medications to avoid rejection of the transplant. He was immunosuppressed as a consequence. He also developed chronic allograft dysfunction and chronic kidney disease and ischaemic heart disease that are recognised long term complications in transplant patients. He developed severe back pain and was admitted to Stepping Hill Hospital on 2nd August 2021. A MR of the spine showed a traumatic wedge fracture of the vertebra at T9. He was given pain relief and subsequently fitted with a brace. On 7th August 2021 he had symptoms of opiate toxicity and was treated with opiate reversing medications. The 1 toxicity was probably as a consequence of an acute kidney injury. He was found to have developed pneumonia and was treated for it. He was placed on NIV due to ongoing acidosis. Subsequently he was stabilised and was weaned off NIV. On 8th September he deteriorated significantly and was again started on NIV and intravenous antibiotics. He stabilised again. Subsequently on 17th September 2021 he began to deteriorate again. Antibiotics were restarted as he showed signs of infection. On 19th September 2021 he was confirmed to be Covid-19 positive having acquired it whilst in the hospital. He was moved to a Covid ward and treated. He subsequently deteriorated further and died at Stepping Hill Hospital on 23rd September 2021. Post-mortem examination confirmed the direct cause of his death was a combination of Covid pneumonitis and pseudomonas aeruginosa bronchopneumonia. 5 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. The Inquest heard that it was recognised that Mr Garrett was at high risk of acquiring Covid-19 in a hospital setting as he was immunosuppressed following his transplant. Despite the risk being recognised he still acquired Covid-19. The Inquest heard that all such patients are at high risk in an acute hospital setting but there is no specific guidance for their management; 2. The evidence before the inquest was that Mr Garratt needed to be discharged as quickly as possible to reduce the risk of acquiring Covid-19. However there was no specific guidance about expediting patients such as him and looking at alternative methods of treatment; 3. His discharge was delayed in part due to opiate toxicity. That arose as a consequence of his kidneys not functioning correctly. The inquest heard evidence that to avoid opiate toxicity is such situations there needs to be a greater use of and understanding of the importance of monitoring kidney function. 6 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. 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29th September 2022. 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 the following Interested Persons namely Stepping Hill Hospital, who may find it useful or of interest. on behalf of the Family and 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 Alison Mutch HM Senior Coroner 04.08.22 3
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 Rt. Hon Andrew Stephenson CBE MP
Minister of State for Health and Secondary Care
39 Victoria Street
London
SW1H 0EU
Alison Mutch
HM Senior Coroner
For the Coroner Area of Greater Manchester South
Coroner’s Court
1 Mount Tabor Street
Stockport
SK1 3AG
13 May 2024
Dear Ms Mutch,
Thank you for your Regulation 28 report to prevent future deaths of 4 August 2022
about the death of Mr Malcolm John Garrett. I am replying as Minister with
responsibility for Health and Secondary Care. Please accept my sincere apologies for
the significant delay in responding to this matter.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr
Garrett’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.
The report raises concerns over:
(i)
(ii)
The Inquest heard that it was recognised that Mr Garrett was at high risk of
acquiring COVID-19 in a hospital setting as he was immunosuppressed
following his transplant. Despite the risk being recognised he still acquired
COVID-19. The inquest heard that all such patients are at high risk in an
acute hospital setting but there is no specific guidance for their
management;
The evidence before the inquest was that Mr Garratt needed to be
discharged as quickly as possible to reduce the risk of acquiring COVID-19.
However there was no specific guidance about expediting patients such as
him and looking at alternative methods of treatment;
(iii) Mr Garratt’s discharge was delayed in part due to opiate toxicity. That arose
as a consequence of his kidneys not functioning correctly. The inquest
heard evidence that to avoid opiate toxicity in such situations there needs
to be a greater use of and understanding of the importance of monitoring
kidney function.
1
In preparing this response, Departmental officials have made enquiries with NHS
England, the Care Quality Commission (CQC) and the UK Health Security Agency
(UKHSA).
You may wish to note that during the COVID-19 pandemic, extensive clinical
guidance was issued by the NHS (eg. Coronavirus (england.nhs.uk) as well as by
the National Institute for Health and Care Excellence (NICE), see Overview | COVID-
19 rapid guideline: managing COVID-19 | Guidance | NICE. More broadly, UKHSA
also issued guidance in relation to patient discharge and infection prevention and
control in health and care settings.1.
With regard to the issue relating to opiate toxicity and the need to understand the
importance of monitoring kidney function. There is general guidance in the British
National Formulary (BNF) in terms of ‘Prescribing in renal impairment’ and every
opiate listed in the BNF will have an entry in relation to renal impairment eg codeine
and morphine both state “Avoid use or reduce dose; opioid effects increased and
prolonged or increased cerebral sensitivity occurs”.
The CQC advised that the matters of concern in this case, namely, hospital acquired
COVID-19 and deaths attributed to a failure in monitoring kidney function are subject
to regular reporting and/or evaluation as part of CQC’s monitoring and engagement
activity. A management review meeting held in August 2022 concluded that neither
concern was reflected in the monitoring data CQC held in relation to this Trust, such
as being an outlier for the management of kidney injury. The Trust was asked at the
time to provide any records or investigation reports relating to the death which the
CQC would consider as part of its ongoing monitoring and engagement to ensure
patients receive safe care and treatment.
The CQC subsequently followed up on this case with the Trust. They advised that the
Trust provided sufficient assurance that they followed national guidance to try to
minimise the likelihood of hospital acquired COVID-19, and to discharge medically
optimised patients as quickly as possible against the backdrop of the limited social
care availability during the pandemic. The CQC also received assurance from the
Trust that they had identified learning and actions in response to complaints and
inquest findings in relation to the clinical management of Mr Garrett’s kidney function.
Due to these assurances, the CQC did not identify a need for further investigation of
this specific case. However, the CQC continues to monitor the Trust’s performance in
relation to hospital acquired infections, discharges and learning from incidents as part
of its ongoing monitoring and engagement.
NHS England also engaged with the Trust and advised that the Trust has a process
in place to manage and reduce the risks of patients in vulnerable groups. They further
advised that the Trust has shared the learning from this incident and that it has
continued to focus on patient discharge.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
1 [Withdrawn] Stepdown of infection control precautions and discharging COVID-19 patients and
asymptomatic SARS-CoV-2 infected patients - GOV.UK (www.gov.uk)
Yours sincerely,
THE RT HON ANDREW STEPHENSON CBE MP
MINISTER OF STATE
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