Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0444, written 12 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Aug 2024 |
|---|---|
| Reference | 2024-0444 |
| Deceased | Nimo Osman |
| Coroner | Ian Potter |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East London 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: Prevention of Future Deaths report Nimo OSMAN (died 23 April 2022) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive Officer East London NHS Foundation Trust Robert Dolan House Trust Headquarters 9 Alie Street London E1 8DE 1 CORONER I am Ian Potter, assistant coroner, for the coroner area of Inner North London. 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 3 May 2022, an investigation was commenced into the death of NIMO OSMAN, then aged 30 years. The investigation concluded at the end of an inquest with a jury, heard by me between 1 July 2024 and 5 July 2024. The inquest concluded with a short-form conclusion of natural causes. The medical cause of death was: 1a hypoxic ischaemic brain injury (unknown aetiology) II pulmonary thrombo-embolism, pneumonia, schizophrenia 4 CIRCUMSTANCES OF DEATH At the time of her death on 23 April 2022, Nimo Osman was in state detention because she was subject to a Hospital Order (in accordance with sections 37 and 41 of the Mental Health Act 1983). Ms Osman was admitted to Rosebank Ward (a psychiatric intensive care unit) at the Tower Hamlets Centre for Mental Health, which is on the Mile End Hospital site, on 5 April 2022. The Tower Hamlets Centre for Mental Health is operated by the East London NHS Foundation Trust. Ms Osman’s principle mental health diagnosis was one of schizophrenia. Between 5-13 April 2022, Ms Osman spent a significant period of time in seclusion. On 19 April 2022, she was observed in a communal area of the Ward in an unresponsive state. A 999 call was made to the London Ambulance Service; however, shortly afterwards, Ms Osman was noted to become responsive and more alert. She was assessed by two doctors on the Ward who considered the most likely explanation was that Ms Osman was over-sedated. A decision was made to cancel the ambulance. Ms Osman was kept under observation and was noted to improve in following 24-hours and blood test results came back within normal limits. Ms Osman collapsed on the Ward on 21 April 2022. An ambulance was called and she was transferred to the Royal London Hospital, where she died on 23 April 2022 as a result of hypoxic ischaemic brain injury. 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 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:- (1) Following the discovery of Ms Osman’s collapse on Rosebank Ward on 21 April 2022, it took staff a significant number of minutes to recognise that instead of just lying on the floor, Ms Osman was actually unrousable. A few minutes later a nurse arrived on the scene, who decided to summon the duty senior nurse (DSN) by radio, rather than activating the alarm system, which would have summoned the rapid response team sooner. The DSN contacted the duty doctor to inform them that there was a medical emergency, prior to calling an ambulance. In total, Ms Osman had been on the floor and unresponsive for over half and hour before an ambulance was called. I also viewed the CCTV evidence covering this course of events. I heard evidence from a consultant neurosurgeon and a consultant neuroradiologist. Their evidence was such that, in Ms Osman’s case this delay would not have made a difference because she had suffered a catastrophic brain injury and her condition was likely to have been unsalvageable from the moment she was found unresponsive on the floor. However, I consider that a delay of circa 30 minutes in calling an emergency ambulance raises a considerable risk, if repeated in the case of another patient requiring emergency treatment at hospital. I was initially reassured by the evidence of a very senior member of nursing staff (Nurse A) about the work that has been done to educate all staff that anyone can call 999 for an ambulance if they consider it necessary, without seeking the advice of colleagues or the specific approval of a doctor. I was told by Nurse A that they were confident that the education and training undertaken with staff had had a positive impact and that a delay of this kind was unlikely to be repeated in the future. However, a senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told me in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told me that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to tell me that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led me to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’. While I was told by Nurse A (who seemed genuinely concerned) that this matter would be escalated and addressed, I was concerned that over two years since Ms Osman’s death this view was still held by a senior and experienced member of the nursing team who led a team of more junior nurses. My concern was such that I am not reassured that sufficient steps have been taken to prevent the recurrence of such a risk in the future. (2) I heard evidence from Nurse A, in the absence of the jury, about East London NHS Foundation Trust’s ‘Patient Safety Serious Incident Review Report’ (the SI Report). I was taken through the detailed ‘Action Plan’ that was devised as a result of the various ‘service delivery problems’ (SDP), ‘care delivery problems’ (CDP), and ‘additional lessons learned’ (ALL) that were identified as a result of the SI Report. Not all of the SDPs, CDPs or ALLs are of such seriousness that I consider that they create a risk of future deaths unless action is taken. However, some of them do, in my opinion, reach that threshold. While the evidence of Nurse A and the accompanying Action Plan did provide prima facie reassurance that action has been taken, the evidence of Nurse B (who, as previously stated is relatively senior and experienced) has significantly undermined what I heard from Nurse A. The undermining of that evidence and reassurance from Nurse A, leads me to conclude that there is, at the very least, a realistic possibility that the learning and apparent changes put in place have not necessarily been fully embedded with all relevant personnel within East London NHS Foundation Trust. As such those concerns and risks persist. For this reason, I consider that further reassurance is required in relation to the following matters of concern: (a) CDP2 – ‘Staff should consider whether patients’ behaviour might be due to being physically unwell and not assume that this is due to their mental health condition.’ This concern relates, in part to the delay in calling for an ambulance (as per (1) above), but in my view it also has potentially wider implications for other patients. (b) CDP3 – ‘As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.’ While in Ms Osman’s case the expert evidence from a consultant histopathologist was that pulmonary thromboembolism was not a causative factor in her death, I consider that this matter does raise potentially significant risks for other patients. (3) With regard to the East London NHS Foundation Trust’s policy in relation to Venous Thromboembolism, I noted during the course of the evidence that this appeared to possibly conflict with NICE guidelines in some respects. There also appeared to be aspects of the policy that were ambiguous and open to different interpretations. I was told the policy remains in force and unchanged. The concern here is that possible ambiguity may lead to a non-universal interpretation of the policy, thereby putting patients at risk. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that you 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 the report, namely by 7 October 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following: (a) Ms Osman’s mother, via her legal representatives. 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. She may send a copy of this report to any person she 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 publication of your response by the Chief Coroner. 9 Ian Potter HM Assistant Coroner, Inner North London 12 August 2024
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.
Office of the Chief Medical Officer Trust Headquarters Robert Dolan House 5th Floor 9 Alie Street London E1 8DE Telephone: Email: Website: http://www.elft.nhs.uk For the attention of HMC Ian Potter Bow Coroner’s Court Bow Road London E3 3AA Private & Confidential Date 7 October 2024 Dear Sir RE: REGULATION 28 REPORT 1. This is a formal response to your Regulation 28 report issued at inquest on 12 August 2024 where you set out concerns relating to the care of Ms Nimo Osman under the East London NHS Foundation Trust’s (the ‘Trust’) care. 2. I understand that at the inquest into Ms Osman’s death, you heard evidence from the Trust’s Deputy Borough Lead Nurse (‘BLN’) for Tower Hamlets outlining the learning that has taken place since her sad death. I understand that you remain concerned about the risk of future deaths in relation to the following areas: 2.1. A senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told you in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told you that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to say that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led you to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’. 2.2. You heard evidence from Nurse A, in the absence of the jury, about East London NHS Foundation Trust’s ‘Patient Safety Serious Incident Review Report’ (the SI Report). Given the evidence of Nurse B, the undermining of that evidence and reassurance from Nurse A, led you to conclude that there is, at the very least, a realistic possibility that the learning and apparent changes put in place have not necessarily been fully embedded with all relevant personnel within East London NHS Foundation Trust. As such those concerns and risks persist. You considered that further reassurance is required in relation to the following matters of concern: 2.2.1. CDP2 – ‘Staff should consider whether patients’ behaviour might be due to being physically unwell and not assume that this is due to their mental health condition.’ This concern relates, in part to the delay in calling for an ambulance (as per (1) above), but in my view it also has potentially wider implications for other patients. 2.2.2. CDP3 – ‘As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.’ While in Ms Osman’s case the expert evidence from a consultant histopathologist was that pulmonary thromboembolism was not a causative factor in her death, I consider that this matter does raise potentially significant risks for other patients. 2.3. With regard to the Trust’s policy in relation to Venous Thromboembolism, you noted during the course of the evidence that this appeared to possibly conflict with NICE guidelines. There also appeared to be aspects of the policy that were ambiguous and open to different interpretations. You were told the policy remains in force and unchanged. The concern here is that possible ambiguity may lead to a non-universal interpretation of the policy, thereby putting patients at risk. 3. I wish to assure you and the family of Ms Osman that the Trust has reviewed the issues highlighted within the Regulation 28 Report and has planned the actions outlined below. RESPONSE Contacting emergency services 4. I share your concerns that one of the Trust’s nurses was under the impression that an ambulance could only be called if under the instruction of a more senior nurse. This is certainly not agreed practice at the Trust. Nursing staff do not require permission to call emergency services. 5. I can confirm, that at the time of Ms Osman’s death and at the inquest, Nurse B’s Intermediate Life Support (ILS) training was up to date. This training is clear in highlighting the expectations of a staff member attending a medical emergency. These expectations include that the staff member will undertake an initial check of the service user, summon s help internally, and ensure an ambulance is called. No permission is required from a senior staff member. Following the inquest, the BLN spoke to Nurse B and Nurse B confirmed that she recognised the need for escalation immediately in medical emergencies as opposed to waiting for senior input. The BLN and Nurse B agreed that Nurse B will complete refresher ILS training. In the meantime, Nurse B has also completed a reflective piece in relation to this matter. 6. This matter was also brought up with all the Lead Nurses at the Trust shortly after the inquest to ensure that the message that ‘permission from senior staff is NOT required to call emergency services’ was disseminated to all nursing staff. As a reminder, this was followed up at the Lead Nurses meeting on 28 August 2024. 7. On 11 September, after a recorded safety discussion with nursing staff on 29 August 2024, the BLN circulated a memo to all Tower Hamlets Wards reinforcing the message that staff consider that service user’s physical health as well as mental health can contribute to their behaviour. It also confirmed that there are no requirements to seek permission to call emergency services via 999. CDP2 8. It is important that all staff are aware of the impact that physical health as well as mental health can have on a service user’s behaviour. As outlined in the BLN’s oral evidence, to ensure this information is embedded, all Tower Hamlets in-patient nursing staff and social therapists undertake a mandatory two-day physical health training course. It includes content on service users presenting as unwell and whether this may be related to their mental or physical health. This course started on 03 May 2023 and is delivered regularly. Further training courses will take place on: • 25 – 26 September 2024 • 14 - 15 October 2024 • 11-12 November 2024 • 16 –17 December 2024. 9. Additionally, Tower Hamlets clinical staff already engage in once weekly emergency scenarios that include when it is appropriate to call 999. By30 November 2025 simulations will take place which include considerations whether something is a physical health verse mental health concern. 10. I understand that the BLN’s oral evidence was that VTE assessments form part of the two-day physical health training outlined in paragraph 8 above. Additionally, both the BLN and Clinical Director for Tower Hamlets circulated an email in January 2023 about the importance of undertaking VTE assessments. This was resent on 1 October 2024 to ensure that staff remain aware of the importance of these assessments. 11. Additionally, all service user admissions are reviewed every morning between Monday- Friday. The Ward Manager or Matron in attendance confirms that a VTE risk assessment is completed. During the weekend and bank holidays, the weekend huddle will consider any admissions and a doctor clerks the patients in. These assessments are audited bi- weekly as part of the service’s physical health assessment audits. 12. Since August 2024, the nurses’ Observations and Measurements form incorporates a screening question for VTE risk. It is a mandatory box to complete on the form and cannot be saved on RiO (the Trust’s electronic record system) until the question has been responded to. VTE Policy 13. It has come to my attention that the inquest only considered the VTE assessment information as provided in the Trust’s Physical Healthcare Policy v.14.1, February 2021. The Trust has a more recent and separate Venous Thromboembolism (VTE) Reducing Risk policy v. 3, March 2023. The information in the VTE policy is unambiguous and in-line with NICE guidelines. It is accepted that the VTE assessment information contained in the Physical Healthcare Policy is not clearly set out. Therefore, the VTE information has been removed from the aforementioned policy in a soon to be published update and it has been made clear that the VTE policy is the appropriate reference. The changes to the Physical Healthcare Policy are expected to be agreed through the Physical Health in Mental Health Committee in November 2024. 14. I hope this response provides sufficient reassurance to you and to the family of Ms Osman about the additional learning that has taken place at the Trust because of her death. 15. I would like to offer my sincere and heart-felt condolences to the family at this difficult time. Yours sincerely Chief Medical Officer Cc:
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