Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0441, written 23 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Apr 2024 |
|---|---|
| Reference | 2024-0441 |
| Deceased | Nuliyati Businje |
| Coroner | Victoria Davies |
| Coroner area | Cheshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. 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 National institute for health and care excellence NICE 2 Department of Health Regulation 28 1 | CORONER Iam Victoria DAVIES, Area Coroner for the coroner area of Cheshire 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 21 April 2017 I commenced an investigation into the death of Nuliyati BUSINJE aged 52. The investigation concluded at the end of the inquest on 18 April 2024. The conclusion of the inquest was that: Narrative Conclusion - Nuliyati Businje died as a result of a massive pulmonary thromboembolism (clot) for which there were a number of factors: - Fluid monitoring was inadequate and the lack of a plan to address this probably caused or contributed to death. - Nuliyati's lack of compliance for diabetes treatment and absence of a plan to address this possibly caused or contributed to her death. - The plan and management from 7 April onwards when Nuliyati's blood sugars were high and uncontrolled with the use of insulin, and when significant changes in her vital signs were seen, and a lack of referral, probably caused or contributed to her death. 4 | CIRCUMSTANCES OF THE DEATH Ms Businje was an inpatient on a psychiatric unit, sectioned under the Mental Health Act. On admission, her VTE risk was assessed and, on the basis that her mobility was not significantly reduced from her baseline, she was deemed to be not at risk and no VTE prophylaxis was given. During her admission she was accepting only limited diet and fluids, and was refusing medication for her diabetes. 8 days into her admission, her physical observations became abnormal (NEWS 7 which included a blood pressure which could not be obtained) and her blood sugar levels were high (20+mmols). The on call doctor was called, who repeated her observations and found these to be normal (NEWS 0). Insulin was given but that evening her blood sugar continued to rise, resulting in an increased dose in insulin. On day 10 of her admission, her blood sugar reading was over 33.1mmols and she subsequently suffered a cardiac arrest. The post mortem examination found a massive pulmonary embolus, due to deep venous thrombosis. Expert evidence was obtained from a consultant physician and he gave oral evidence in court. He explained that Ms Businje had a number of risk factors for DVT, including dehydration, her age and obesity. In his view, the risk assessment should not have stopped once significantly reduced mobility was ruled out, as her other risk factors would necessitate the need for VTE prophylaxis. He was surprised when it was pointed out to him that the Department of Health VTE risk assessment tool in place then (2017) and still in place now suggests there is no need for further assessment. A consultant psychiatrist on Regulation 28 — After Inquest Document Template Updated 30/07/2021 behalf of the Trust gave evidence that there is a growing body of research which indicates that psychiatric patients on a ward are also at higher risk of DVT and as such they have amended their local assessment tool to consider other factors over and above mobility. 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) 1. Despite evidence to suggest that mobility is not the ultimate deciding factor of risk of DVT, the risk assessment tool as currently drafted and relied upon by clinicians would suggest that there is no further need for assessment. This raises a risk of future deaths for those patients such as Ms Businje who were at risk of VTE, or those with cancer for example, but who do not have significnstly reduced mobility and would therefore fall outside of the risk assessment. 2. Based on the evidence I heard, patients on a psychiatric unit are at increased risk of DVT but this is not factored into the risk assessment, nor the NICE guidance. The latter guidance has a specific section for psychiatric patients but does not provide any specific information as to risk and directs the reader to the same Department of Health risk assessment tool. 3. Based on the evidence of the expert physician, a common presentation of a clot can be a derangement in observations such as respiratory rate and heart rate, but these can normalise as the clot passes further on and the blockage eases. I am concerned that this does not appear to be widely known, is not part of training at least in the Trust in this case due to the lack of awareness, and I am told is not something which is taught nationally. There is a risk that a clinician without this knowledge would, as in this case, be reassured by the improving observations and the clot, and risk of a further more serious clot, would be overlooked. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by June 18, 2024. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Solicitor for the family- Solicitor for Solicitor for Solicitor for Cheshire and Wirral Partnership NHS T- I have also sent it to Regulation 28 — After Inquest Document Template Updated 30/07/2021 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. Dated: 23/04/2024 Dawes Victoria DAVIES Area Coroner for Cheshire Regulation 28 — After Inquest Document Template Updated 30/07/2021
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.
Parliamentary Under-Secretary of State for Patient Safety, Women’s Health and Mental Health 39 Victoria Street London SW1H 0EU 22 July 2024 Our Ref: Victoria Davies Area Coroner Cheshire's Coroner's Service Museum Street Warrington Cheshire WA1 1JX By email: Dear Victoria, Thank you for your Regulation 28 report to prevent future deaths dated 23 April 2024 about the death of Nuliyati Businje, and I’d like to thank you for agreeing an extension. I am replying as the newly appointed Minister with responsibility for mental health and patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of Nuliyati’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are deeply concerning and I am grateful to you for bringing these matters to my attention. Your report raises concerns over the assessment of the risk of deep vein thrombosis (DVT) amongst psychiatric inpatients and the guidance on this provided by the National Institute for Health and Care Excellence (NICE). It is essential that mental health settings meet inpatients' physical as well as mental healthcare needs either through their own appropriately qualified and experienced staff or in partnership with other providers. This requires mental health inpatient staff to be provided with adequate training and guidance on monitoring physical health, and importantly how to escalate and respond to concerns as needed. It is recognised that inpatients on psychiatric wards may be at higher risk of venous thromboembolism due to reduced mobility, poor fluid intake, restraint, catatonia, sedation and antipsychotic use. NICE’s guidance on Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism (NG89) makes clear that all acute psychiatric patients should be assessed to identify VTE and bleeding risk on admission, using a risk assessment tool. The Department will work with NHS England to consider the VTE risk assessment tool, in light of the concerns you have raised. I note that you have also written directly to NICE. As NICE is an independent body, it will be for NICE to review its current guidance to see if any updates are needed and I would expect that NICE will want to take your concerns into account as part of this process. I hope this response is helpful and demonstrates my sincere desire to improve care for patients so we can avoid such tragedies from occurring. Thank you for bringing these important concerns to my attention. Yours sincerely,
NIC National Institute for 24 Floor Health and Care Excellence 2 Redman Place London E20 1JQ United Kingdom +44 (0)300 323 0140 18 June 2024 Ms Victoria Davies Area Coroner for the coroner area of Cheshire Cheshire Coroner’s Service Museum Street Warrington Cheshire WA1 1JX Your ref: Our ref: Dear Ms Davies, | write in response to your regulation 28 report of 23 April 2024 regarding the very sad death of Ms Nuliyati Busunje. | would like to express my sincere condolences to Ms Busunje’s family. We have reflected on the circumstances surrounding to Ms Busunje’s death and the concerns raised in your report. With regard to the assessment of VTE risk in people with psychiatric disorders admitted to hospital, in the NICE guideline on venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism we recommend that clinicians should use ‘a tool published by a national UK body, professional network or peer-reviewed journal’ to assess VTE risk, however we do not recommend a particular risk assessment tool as there is not enough evidence to support the use of one over another and during development of the guideline, the committee made a research recommendation in this area, reflecting the uncertainty in the evidence for one risk tool over another. The Department of Health’s national risk assessment for VTE, highlighted in recommendation 1.9.1, has been widely used in the NHS to assess a person’s risk of VTE since 2010, however it has not been validated or tested against other tools to evaluate its diagnostic accuracy or effectiveness at correctly identifying people at risk of VTE. As such, we explain that the tool is commonly used to develop a treatment plan for psychiatric patients. However, clinicians can and should choose a different tool if it better fits the clinical circumstances of the patient. Concerns regarding the risk assessment tool referenced in NG89 would need to be directed to the Department of Health and Social Care. We agree that people with psychiatric disorders may be at risk of developing venous thromboembolism, particularly when acutely unwell and admitted to hospital, and that that risk assessment should not stop once significantly reduced mobility has been ruled out as other risk factors may be present. The committee recognised that the risk of VTE in these patients may be due to the presence of several risk factors including reduced mobility due to psychiatric illness or sedation, but also dehydration due to poor oral intake, or comorbid physical illness, and this should be included in the risk assessment. The committee also noted that as with other populations, prophylaxis decisions for NICE www.nice.org.uk | nice@nice.org.uk psychiatric inpatients should be clearly documented and they should be reassessed throughout their stay as it likely that their clinical condition could change unexpectedly. We believe that our recommendations for assessment and review cover the clinical circumstances outlined in your report. In NG89 we recommend that all people admitted to an acute psychiatric ward should be assessed for risk of VTE at consultant review or if their clinical condition changes (recommendation 1.9.2). Further, we recommend that clinicians should consider pharmacological VTE prophylaxis for people admitted to an acute psychiatric ward whose risk of VTE outweighs their risk of bleeding and that this should be continued until the person is no longer at risk (recommendations 1.9.3 and 1.9.5). We note the observations of the consultant physician regarding a growing body of research which indicates that psychiatric patients on a ward are at higher risk of DVT. As discussed above, the risks pertaining to this population were discussed by the committee and is reflected in our recommendations. We are aware of a recent retrospective study which showed no difference in the VTE rates following psychiatric inpatient admission compared to unselected acute medical admission. The signs and symptoms of a pulmonary embolus (PE) are discussed in the Clinical Knowledge Summary on Pulmonary Embolus. This notes that the signs and symptoms of pulmonary embolism are non-specific, but symptoms typically have a sudden onset, and that PE may be completely asymptomatic and be discovered incidentally when assessing for another condition. The recommendations on when to suspect PE is based on clinical features of PE described in the NICE and European Society of Cardiology (ESC) guidelines [NICE, 2023; Konstantinides, 2020] and the BMJ Best Practice guide [BMJ Best Practice, 2022]. NICE recommends considering using the Pulmonary embolism rule-out criteria (PERC) rule if clinical suspicion of PE is low, based on the overall clinical impression, and if other diagnoses are feasible. However, given the non-specific nature of presenting symptoms, clinicians need to have a high level of suspicion in people with risk factors for PE. Again, | offer my sincerest condolences to Ms Busunje’s family. Yours sincerely, Chief Executive Page | 2
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.