Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0662, written 3 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 | 3 Sep 2024 |
|---|---|
| Reference | 2024-0662 |
| Deceased | Samsam Ateye |
| Coroner | Anton Van Dellen |
| Coroner area | West London |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. NHS England 1 CORONER I am Dr Anton van Dellen, HM Assistant Coroner, for the coroner area of West 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 An investigation was commenced into the death of Samsam Haji Ali Ateye, aged 68. The investigation concluded on 30 August 2024. The conclusion in the inquest was: Complications following surgical procedure. The medical cause of death was 1a Multiorgan failure 1b Following bio prosthetic aortic valve replacement surgery 1c Aortic stenosis with ventricular hypertrophy and fibrosis II Disseminated intravascular coagulopathy and thrombocytopenia with microvascular thrombotic involvement of hands and feet (managed conservatively), adult respiratory distress syndrome and acute bronchopneumonia 4 CIRCUMSTANCES OF THE DEATH Samsam died on 12 May 2023 at Harefield Hospital, Uxbridge. She had been diagnosed with severe aortic stenosis which was symptomatic. A Multi-Disciplinary Team (MDT) meeting decided that she would benefit from aortic valve replacement surgery. She had an out-patient pre-operative Covid-19 Polymerase Chain Reaction (PCR) test performed on 18 April 2023, which was negative. She was admitted to hospital on the day of her surgery on 20 April 2023. On admission, she had another Covid-19 PCR test performed on her that morning, before her surgery. She had aortic valve replacement surgery that afternoon. Post-operatively, the surgeons who operated on her became aware, that evening, that the Covid-19 PCR test performed on her on the morning of surgery was positive. A subsequent three further Covid-19 tests performed in hospital after 20 April 2023 were also positive. Post-operatively, she developed episodes of atrial fibrillation, as well as sepsis which was probably bacterial and was of unknown origin. She died due to sepsis which caused Multi-Organ Failure. The inquest heard evidence that the consultant surgeon was very worried upon learning that Samsam was Covid positive as patients who are Covid positive who undergo cardiac surgery have a real risk of excessive complications and mortality. The inquest heard that policy about pre-operative testing for Covid for cardiothoracic surgery and the form of that testing was formulated at a national level by NHS England. 1 5 CORONER’S CONCERNS During 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. The policy for testing for Covid-19 before cardiac surgery, specifically valve replacement surgery.. 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 29th October 2024. 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Guys and St Thomas’ NHS Foundation Trust 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 other 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. 3rd September 2024 9 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.
Dr Anton Van Dellen
HM Assistant Coroner for West London
West London Coroner’s Office
25 Bagley’s Lane
Fulham
SW6 2QA
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
22 November 2024
Re: Regulation 28 Report to Prevent Future Deaths – Samsam Haji Ali Ateye
who died on 12 May 2023
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 3
September 2024 concerning the death of Samsam Haji Ali Ateye on 12 May 2023. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Samsam’s family and loved ones. NHS England are
keen to assure the family and the Coroner that the concerns raised about Samsam’s
care have been listened to and reflected upon.
I am grateful for the further time granted to respond to respond to your Report, and I
apologise for any anguish this delay may have caused to Samsam’s family or friends.
I realise that responses to Coroner Reports can form part of the important process of
family and friends coming to terms with what has happened to their loved ones and
appreciate this will have been an incredibly difficult time for them.
Your Report raised concerns over the policy for testing for COVID-19 before cardiac
surgery, specifically valve replacement surgery.
NHS England published advice on COVID-19 testing for elective care pre-admission
patients in early 2022. This can be found here: NHS England » COVID-19 standard
operating procedure: testing for elective care pre-admission patient
The document advises that a risk-based approach should be taken between patients
and clinical teams in all cases, including where test results are positive. Individual NHS
Trusts are responsible for implementing and following processes to manage COVID-
19 risks and appropriately consent patients.
This approach is reflective of guidance (second version published in February 2022
and latest version published in June 2023) by The Association of Anaesthetists,
Federation of Surgical Speciality Associations, Royal College of Anaesthetists, and
the Royal College of Surgeons. Both versions make clear the need for risk assessment
to balance the risks of proceeding with surgery versus postponement, considering the
severity of the patient’s illness/condition and the severity of their COVID-19 infection.
NHS England notes that the Royal Brompton & Harefield NHS Foundation Trust,
where Samsam underwent her surgery, published a COVID-19 and heart surgery
Patient Information Leaflet in May 2020. This states that where patients receive
positive COVID-19 test results, transfer to Harefield Hospital cannot happen
straightaway, and that an expert panel will review cases where delaying operations
poses a high risk. It is difficult for NHS England to provide further comment on
Samsam’s care from the information in your Report and it is not clear why the operation
went ahead before the results of the second COVID-19 PCR test were known. I would
therefore refer the Coroner to the Trust for further information and for their most up-
to-date position on COVID-19 pre-operative testing.
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 events, such as the sad death of Samsam, are shared
across the NHS at both a national and regional level and helps us to 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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