Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0491, written 11 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Sep 2024 |
|---|---|
| Reference | 2024-0491 |
| Deceased | Nisren Abdul-Karim |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Manchester University 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Greater Manchester Integrated Care CORONER 1 I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester 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 5th August 2024 I commenced an investigation into the death of Nisren ABDUL-KARIM. The investigation concluded on the 19th August 2024 and the conclusion was one of Narrative: Died from natural causes contributed to by the complications of an accidental fall sustained whilst unobserved as an inpatient. The medical cause of death was 1a) Hospital acquired pneumonia 1b) Frailty 1c) End stage neurodegenerative condition II) Fall (1st Nov) requiring surgery for hip fracture (2nd Nov), Behcet's disease. 4 CIRCUMSTANCES OF THE DEATH Nisren Abdul-Karim had a number of underlying health conditions including Behcet's disease. In Autumn 2023 she began to hallucinate. She was admitted again to Wythenshawe Hospital on 21st October 2023. She was a high falls risk. Whilst an inpatient and unobserved she had a fall. She should not have been unobserved. She was operated on for a fractured hip sustained in the fall. She was transferred to Trafford General Hospital for rehabilitation on 10th November. The transfer meant that access to neurology was more difficult because the service provided by neurologists was not available at Trafford General Hospital. She continued to deteriorate at Trafford General Hospital. Further advice was sought via patient pass from the neurology team at Salford Royal Hospital. Review of the scans previously undertaken concluded that she had irreversible neurodegenerative disease. She continued to deteriorate and died at Trafford General Hospital on 5th January 2024. 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. 1 The MATTERS OF CONCERN are as follows. – The evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass. This meant accessing the notes required recognising that patient pass needed to be accessed. In addition the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology. As a consequence delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all contact with neurology is via telephone or patient pass as there is no face to face neurology service. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 6th November 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 Interested Persons namely Manchester University NHS Foundation Trust, on behalf of the family, 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. 2 9 Alison Mutch Senior Coroner 11/09/2024 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.
E: Date: 19 November 20204 Private & Confidential Ms Alison Mutch OBE Senior Coroner for Greater Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Sent by email to: Dear Ms. Mutch Re: Regulation 28 Report to Prevent Future Deaths regarding Mrs. Nisren Abdul-Karim Thank you for your Regulation 28 Report dated 11 September 2024 regarding the sad death of Mrs. Nisren Abdul-Karim. On behalf of NHS Greater Manchester (NHS GM), We would like to begin by offering our sincere condolences to Mrs. Karim’s family for their loss. Thank you for highlighting your concerns during the inquest which concluded on 19 August 2024. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services. During the inquest you identified the following cause for concern: - The evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However, the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass. This meant accessing the notes required recognising that patient pass needed to be accessed. In addition, the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology. As a consequence, delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all 4th Floor, Piccadilly Place, Manchester M1 3BN www.gmintegratedcare.org.uk Tel: contact with neurology is via telephone or patient pass as there is no face-to-face neurology service. NHS GM have communicated with both provider Trusts, namely the Northern Care Alliance (NCA) and the Manchester University NHS Foundation Trust (MFT) to formulate this response. I hope the below offers assurances to both you and Nisren Abduls-Karim family that NHS GM continues to take these concerns seriously and has put in a number of steps and actions since the tragic death of Nisren Abdul- Karim. We have identified that at that time there was no visiting neurologist covering the Trafford site. The NCA have identified this as a gap in their provision and have since recruited a neurologist who will cover the Trafford site. This role will include weekly input from neurology in terms of seeing referrals at the Trafford site. The NCA convened a working group to improve its understanding of Patient Pass and improve the system itself to reduce the likelihood of recurrence of such an incident. In addition, the NCA have prepared a communication guide, which outlines the purpose of Patient Pass and clarifies the responsibilities of referrers and receivers. This document is due to be finalised by the end of November and will be circulated across Greater Manchester hospitals via their Medical Directors, including MFT and the Trafford site. The NCA have provided reassurance that the system will be audited regularly to ensure adherence to the referral guidelines, with feedback being issued to the referring Trust as required. The neurology team provide ward reviews to all GM hospital sites. This is with the exception of Rochdale. As Rochdale is not an acute site, there has never been the demand for neurology inpatient reviews. Any site can always access Neurology opinion via the on-call service 24/7, and advice will be provided. Requests for ward reviews come through Patient Pass. There is currently variation in process in terms of on-going documentation after that initial request via the system. In some cases, on-going clinical advice is continued on Patient Pass (akin to how this works for on-going neurosurgical or spinal advice through the same system). This requires local hospital-based clinicians to access Patient Pass to see the documentation. In other cases, on-going clinical advice is written in the local hospital site’s notes, on whatever system exists on that site for this. The NCA propose that all neurology advice is provided via the Patient Pass system, in line with other tertiary services of neurosurgery and spinal surgery. The NCA believe that if this was in place it would prevent a recurrence of this issue. There are plans in place to update the Patient Pass system, which will include a telephone number as a mandatory field. Any non-urgent advice will continue to be provided via the Patient Pass system, and the communication guide will also advise the referrer that Patient Pass should be accessed regularly for on- going communication with the tertiary service. The tertiary services are also required to attempt to contact the referring service via telephone when there is time critical action required by the referrer, supplemented by appropriate documentation in Patient Pass. In addition to this, there are expectations on referrers and the tertiary service at an organisational level to ensure that potential users of Patient Pass are aware of how to use the system. I hope the above offers you reassurance of the ongoing commitment to managing patient safety risks and to continually improve the care and services we provide. Please do not hesitate to contact me if you require any further information in relation to our response. Best wishes 4th Floor, Piccadilly Place, Manchester M1 3BN www.gmintegratedcare.org.uk Tel: 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
See every Prevention of Future Deaths report matching Manchester University NHS Foundation Trust, 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.