Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0165, written 31 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Mar 2025 |
|---|---|
| Reference | 2025-0165 |
| Deceased | Abu Rahman |
| Coroner | Harry Lambert |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Alcohol, drug and medication 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.
Findings of Fact Dr. Abu Rahman, retired consultant geriatrician, was born on the 25th of December 1935. So, by November 2024, the period of which this investigation is concerned, he was aged 88 years. Like any octogenarian, he had a medical history and this included end-stage renal failure and Type II Diabetes Mellitus. According to , whose written evidence I considered carefully, he had been recently discharged from hospital, having been an inpatient treated for hospital acquired pneumonia. On the 7th of November 2024, Dr Rahman was involved in a minor road traffic accident. The police attended and he declined medical attention on a number of occasions. Attending officers very sensibly decided that they would wait with Dr. Rahman until the arrival of a taxi, which was to take him home. This statement of says as follows: ‘I held him up by his arms, and he had a bit of support to walk with him, and walked him slowly over to the car. At this time, I noticed how unsteady he was on his feet when the distance between the car and the wall was no more than 2 meters. So I held him up as much as possible and got him to the car door. I then reached down to the door to sit him in, and as I had stood up from doing this, I can see he's begun to stumble and fall backwards. Where I then tried to stop his fall and catch him, which was of no use as I couldn't catch him in time’ Dr. Rahman immediately identified that he had broken his hip. He was subsequently admitted to Royal Free. Upon admission, his creatinine levels were 417, which was almost identical to a previous reading of 419 a month previously, in October 2024. This is significant because it shows that the renal impairment which later became a feature of his admission had not yet commenced. The next day, 8th November, he underwent an uncomplicated left cemented hemiarthroplasty from which he initially appeared to be recovering well. He was, in the words of his daughter , from whom I heard evidence, “in great spirits”. I shall refer to , another medically qualified Rahman doctor, as “SR” to distinguish her from her father. Of the course of the next few days his condition remained stable and on 9th November he mobilized with a walking frame, progress with which he was very pleased one day post- operatively. On 10th November Dr Rahman suffered from a hallucination which SR felt was secondary to the administration and accumulation of opioids; her father had supposedly suffered a similar reaction 1 in 2017 in the context of bowel surgery. She asked for no more opioids to be prescribed, although she accepted in evidence that at this stage her father still had capacity. Despite being medically qualified, she did not feel that she was “heard” by treating staff, in this regard. On 11th and 12th November Dr Rahman is still described in the medical notes as “stable” but SR described in some detail how, as matters unfolded, “each day things became gradually worse”. The last dose of oxycodone was given on 11th November at 1004. On 12th November Dr Rahman was “getting confused” and SR describes being “certain” that she witnessed her father aspirate after being fed by an HCA. This too is potentially important given what later transpired and the possibility of aspiration pneumonia being implicated in Dr Rahman’s death. By 13th November, whilst his observations were stable, he was described as sleepy. His creatinine was 431, indicating that his kidney function was slightly worse. His CRP, which is a marker of infection, was 288.9. As remarks, it's difficult to determine the importance of that in the context of post-operative care, but it is nevertheless worthy of note, given what later transpired, and the possibility of hospital acquired pneumonia. A chest X-ray that day demonstrated patchy consolidation in keeping with aspiration pneumonia. The 13th was the first time the putative diagnosis of “hypoactive delirium” was mooted. SR, who as I say is medically qualified, but does not give evidence in her capacity as a doctor, disputes this diagnosis and attributes the drowsiness to the continuing effect of opioids. SR candidly accepted that she did not have the expertise to comment on or second-guess ’s opinion that the recorded dosages (which were not in dispute) were “small, judicious and reasonable”. To that extent was not critical of . Nevertheless, it is perfectly possible that any toxicity arose through no fault of , and indeed my attention was drawn to medical literature to the effect that just such a phenomenon has been noted in post operative patients in renal failure (Conway et al, 2006). Interestingly Naloxone – a therapy to reverse opioid toxicity – was given on this date. Also of interest is that SR’s husband, , who was present on this date, is recorded in s statement as describing Dr Rahman as “cognitively sharp, but unable to stay awake for long periods”. There was therefore no suggestion that he was “not himself”. 2 She further relayed, and relied upon, the fact that a diagnosis of opioid toxicity was reached by . Although there is a slight difference in emphasis and timing, this is essentially consistent with ’s recollection at Paragraphs 26 and 28. On 14th SR recalls seeing myoclonic jerks (a sign of opioid toxicity) as well as hearing explaining the “classical signs of opioid poisoning” (or words to that effect) to one of his students. Again, Naloxone was given. SR’s recollection is that in response to Naloxone, Dr Rahman’s condition improved. She recounts that by 16th November (a date not covered in ’s statement, because he was not working that day) he was “over the worst” and “recovering from surgery”. Her evidence is that a decision was unilaterally taken by a junior doctor to stop Naloxone, and then re-prescribed on 18th. Nevertheless, her evidence was that there were often logistical difficulties, with treating staff frequently running out of Naloxone and having to visit the pharmacy to obtain more. This happened on a number of occasions, meaning that there were “hours and hours” when Dr Rahman did not have any Naloxone. It is common ground that Dr Rahman then deteriorated over the course of 19th and 20th November. His kidney function on the 19th of November had deteriorated further with a creatinine of 613. SR described how he was “re-aspirating each time he lost consciousness”. A chest X-ray on the 20th November, however, showed increased ground glass changes with multifocal nodular air space opacities within the left lung and the right mid to lower zone in keeping with underlying infective process. He was reviewed by and was found to have severe metabolic acidosis, secondary to renal failure. agreed with the family that the patient was for palliative care. Dr Rahman sadly passed away, and he was confirmed deceased at 1639. Dr Noimark produced a proposed MCCD of: 1a Hospital-acquired pneumonia 1b Fractured Neck of Femur 3 1c Traumatic Fall 2 End stage renal failure, and Type II Diabetes Mellitus. SR maintains that the pneumonia was aspiration pneumonia, as opposed to hospital- acquired/infective. There is radiological support for both propositions. It is difficult to distinguish the two, as himself acknowledges, and in my judgment I (a) do not need to do so to fulfil the statutory purpose of an inquest and (b) in any event lack the evidence to do so and cannot indulge in speculation. I consider that I am required, however, to resolve the issue of whether or not Dr Rahman suffered opioid toxicity (a) at all and (b) as opposed to hypoactive delirium. In this regard I find in favour of SR that Dr Rahman indeed suffer from opioid toxicity, and that he did not suffer from hypoactive delirium. I do so for the following reasons: (1) Naloxone was prescribed, which is drug whose sole purpose is to reverse opioid toxicity. (2) Specifically Naloxone was prescribed by , which supports SR’s recollection that he diagnosed opioid toxicity and was pointing out its classical features to his student. I find that the latter detail also has the ‘ring of truth’ to it, and indeed there is and could be no proper suggestion that SR is anything other than a truthful witness doing her best to assist the court. (3) The presence of myoclonic jerks. (4) At the onset on the so-called hypoactive delirium, Dr Rahman was described as “cognitively sharp, but unable to stay awake for long periods”. There was therefore no suggestion that he was “not himself”. This fits better with a picture of opioid toxicity. (5) No plausible cause for the hypoactive delirium has been proposed, especially in circumstances where Dr Rahman initially appeared to be recovering well from surgery. For the avoidance of any doubt, in making this finding I do not intend any criticism of . As to whether the opioid toxicity was implicated in the death, I remind myself of R (Tainton) v HM Coroner for Preston and West Lancashire [2016] EWHC 1396(Admin)where it was said that for 4 causation of death to be established, the threshold is “whether on the balance of probabilities, the event or conduct more than minimally, negligibly or trivially contributed to the death”[para.41]. The relevant event “must make an actual and material contribution to the death of the deceased” [para.62]. I note that Dr Rahman’s condition had, on SR’s evidence, significantly improved by the 16th November to the extent that he was said to be recovering well. This was five days after his last dose, and following the administration of Naloxone, which continued albeit intermittently. I also note that I do not have any medical or expert evidence to the effect that opioid toxicity was implicated, save for ’s remark in his supplemental statement that “opioids may have contributed to drowsiness and increased risk of pneumonia”. Against that background, and given the breadth of Dr Rahman’s co-morbidities, I find that I lack the evidence to make this positive finding. I therefore accept ’s proposed MCCD, save for the words “hospital acquired” in 1a: As to the issue of PFD, I have considered both Conway et al and taken judicial notice of the British Renal Society’s Kidney Patient Safety Committee: Safe prescribing of opiates in kidney disease which describes how: 15% of the population has chronic kidney disease and acute kidney injury is seen in up to 20% patients who are admitted to hospital for emergency care. Pain affects more than 50% of patients with advanced chronic kidney disease, with more than half describing this as moderate to severe. Despite its high prevalence, the recognition of pain and its management in patients with renal impairment is complicated and poorly understood. Prescribers’ awareness of the choice of opioids and methods of assessment of renal impairment shows great variability and often there is limited knowledge in care settings where specialist renal input is not available This very much tallies with the oral evidence of SR’ about a lack of recognition and thus, whilst the matter is finely poised I am on balance persuaded to return a PFD Report. The Report will deal with the issue of (a) raising awareness of opioid toxicity in patients with renal impairment and (b) the administrative delays in securing medication from the pharmacy. A copy will be provided to interested persons. In summary: 5 (1) I lack the evidence to determine whether the pneumonia was Hospital-Acquired or Aspiration-based. (2) I do however find that there was opioid toxicity and no hypoactive delirium; (3) I am not in a position to find that this caused or contributed to the death; (4) I am issuing a PFD Report. 6
Regulation 28: Prevention of Future Deaths report
Abu RAHMAN (died 20.11.2024)
THIS REPORT IS BEING SENT TO:
The Medical Director, CEO and Legal Department of:
Royal Free Hospital
Pond Street
London NW3 2QG
1
CORONER
I am: Harry Lambert
Assistant Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 21 November 2024 an investigation was commenced into the death
of Abu Rahman aged 88 years. The investigation concluded at the end
of the inquest held on 25th and 26th March 2025.
The Inquest found that Abu Rahman, aged 88, suffered a traumatic fall
in which he broke his hip. He underwent hemi-arthoplasty from which
he initially recovered well. He later deteriorated, his decline driven by
pneumonia on a background of pre-existing end stage renal failure.
The medical cause of death was:
1a Pneumonia
1b Fractured Neck of Femur
1
1c Traumatic Fall
2 End stage renal failure, and Type II Diabetes Mellitus.
I returned a Conclusion of Natural Causes.
4
CIRCUMSTANCES OF THE DEATH
Please see attached Findings of Fact.
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.
Firstly, I heard evidence from the family that nursing staff were frequently
unable to administer Naloxone as it had run out. They had to obtain more
Naloxone from the pharmacy, which led to delays for “hours and hours”
on multiple occasions.
Secondly, I heard evidence concerning a lack of awareness or
appreciation concerning the risk of opioid toxicity / accumulation in
patients with kidney impairment/failure, even where the “correct” dose
may have been given.
I am concerned that if there is no proper or properly implemented system
for obtaining medication in a timely manner, and limited awareness of
the matters canvassed above, then this gives rise to a risk of future
deaths.
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.
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 29 May 2025. 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 following.
• The British Renal Society / UK Kidney Association
• HHJ Alexia Durran, the Chief Coroner of England & Wales
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.
9
DATE SIGNED BY ASSISTANT CORONER
31.03.25
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.
Royal Free London Hospital Group,
Pond Street,
London
NW3 2QG
Phone: 020 7794 0500
Private and Confidential
His Majesty’s Assistant Coroner Harry Lambert
St Pancras Coroner’s Court
Camley Street
London
N1C 4PP
Via Email
28 May 2025
Dear Sir,
Re: Regulation 28: Prevention of Future Deaths report – Abu Rahman (date of death: 20
November 2024)
We write to you in response to the Regulation 28: Prevention of Future Deaths report following
the inquest into the death of Dr. Abu Rahman.
We would like to reiterate our sincere condolences to the family of Dr. Rahman for their loss.
The Royal Free London NHS Foundation Trust has carefully considered the matters of
concern raised in the Regulation 28 Report.
We note that the two consultants involved in the case (an orthopaedic surgeon and a
consultant geriatrician physician) submitted written statements but were not summoned to
attend the inquest. We are grateful for the opportunity to respond to the matters you have
raised.
The inquest took place on 25 and 26 March 2025 and raised two matters of concern which
have been responded to in turn below:
1. Firstly, I heard evidence from the family that nursing staff were frequently unable to
administer Naloxone as it had run out. They had to obtain more Naloxone from the pharmacy,
which led to delays for “hours and hours” on multiple occasions.
It is recognised that the process of initiating Naloxone in Dr Rahman’s case was not in line
with available best practice guidance. Bolus injections of Naloxone are recommended, to
assess the response from the patient and an infusion is commenced thereafter with the dose
titrated according to the amount required to achieve an initial response. It is acknowledged
that awareness of this process should be shared amongst the medical team in the Acute
Medicine and Elderly Care specialities for improved management of patients in ward-based
settings.
Naloxone supply on ward 8 North is a mandatory stock item which needs to be fulfilled,
replenished and maintained in a timely manner. Naloxone stock is checked weekly, by the
stock control pharmacist, monthly by the ward manager/ matron to ensure this supply is
consistently available. Ward manager/ Matron checks are mandatory also and this is audited
monthly through Tendable.
Tendable is a digital platform and mobile app designed to streamline and enhance quality
audits in healthcare settings, including nursing audits.
Naloxone is kept in all ward areas as part of standard requirements for the management of
opioid toxicity. It is also available in the emergency drug cupboards and further advice on
obtaining supplies is available during out of hours periods through the on-call pharmacist.
Access to Naloxone during Dr Rahman’s time on 8 North was not reported to be disrupted and
his medication chart records that it was administered to him between 24 minutes and 1 hour
following the prescription being made, despite the significant quantity that was used. It was
concluded that this was a highly unusual circumstance, in which Dr Rahman was receiving
ongoing infusions, requiring an unusually large quantity of Naloxone, as a result impacting the
time to administer.
Clarity on the process of accessing Naloxone, including out of hours, should stock need
replenishing will be shared at daily huddles for two weeks. In addition, pharmacy will be
increasing the stock level on 8 North ward to reduce the likelihood of it not being immediately
available. Stock levels have been increased from 2 boxes to 3 boxes which under expected
usage levels provides a sufficient supply for more than 24 hours.
2. Secondly, I heard evidence concerning a lack of awareness or appreciation concerning the
risk of opioid toxicity/ accumulation in patients with kidney impairment/failure, even where the
“correct” dose may have been given.
During Dr Rahman’s time on ward 8 North and following the initial Naloxone infusion there
were various components which determined his clinical condition which were consistently and
appropriately managed throughout his admission.
Dr Rahman attended Royal Free Hospital (RFH) Emergency Department (ED), following a
road traffic accident and subsequent fall, resulting in a left intracapsular fracture of the neck
of femur (NOF). On admission to Royal Free Hospital Dr Rahman underwent surgery (a left
cemented hemiarthroplasty) on 8 November and was noted to be recovering well. However,
in the days following, his daughter raised concerns of the administration and accumulation of
opioids, as Dr Rahman had an increase in drowsiness and showed signs and symptoms of
delirium.
On 14 November, Naloxone was given and although Dr Rahman showed some improvement
in relation to his level of alertness this was not an immediate response that would be expected
when dealing with opioid toxicity. There is evidence of regular assessments of Dr Rahman’s
level of alertness including pupil size and responses and there doesn’t appear to be any
correlation with the administration of the naloxone. The medical team involved in Dr Rahman’s
care continued the Naloxone infusions at the wishes of his daughter.
Dr Rahman’s analgesia was prescribed in line with the new national advice issued via the
MHRA regarding the use of opioids for the relief of post-operative pain. This advice was
assessed through the Drugs and Therapeutics Committee and Medicines Safety Committee
and enacted rapidly in advance of Dr Rahman’s admission. In addition, a new prescribing
process has been developed for the EPR system to support prescribing clinicians and
improve patient safety.
The Royal Free Hospital is a regional centre for renal medicine with active input to patients in
outpatient and inpatient settings, including for Dr Rahman. This also extends to local guideline
development which are written to account for the needs of our hospital population of patients
with chronic kidney disease. Oxycodone is the strong opioid recommended for use in acute
pain for patients with renal impairment within the local prescribing guideline, Acute Pain in
Adults Prescribing Guide, available through Freenet (Royal free Hospital Intranet resource).
Considering Dr Rahman’s diagnosis of end stage renal failure the half-life (the time it takes for
the amount of a drug’s active substance in your body to reduce by half) of oxycodone in
patients increases by up to 1.7 times compared to patients with normal renal function. A review
by a Consultant Nephrologist and Lead Renal Pharmacist confirmed that the final dose of
Oxycodone administered at 10:04 on 11 November 2024 would have been expected to have
been metabolised that afternoon. From the information gathered, following a review of the
patient's medical records with input from an expert panel, it was concluded that the patient in
this case was unlikely to have opioid toxicity.
Unfortunately, this does not appear to be reflected in the statements submitted and the clinical
team were not invited to attend court in order so did not have the opportunity to give further
clarification.
The patient subsequently developed a pneumonia, and sadly deteriorated. The hypoactive
delirium appeared most likely to have contributed to acute this deterioration, in addition to his
renal failure and other significant parallel co-morbidities.
The Trust is committed to learning from Dr Rahman’s tragic death and continuously improving
patient safety. We will actively monitor adherence to the ongoing improvement plans and the
Trust’s action plan is set out below. This will be monitored by the Acute Medicine, Emergency
Department and Elderly Care (AMEDEC) Divisional Quality & Safety Board and the Clinical
Performance and Patient Safety Committee.
Action Plan
Safety action description
Relevant Recommendation -
Responsibility for
monitoring/ oversight
Action Deadline
Evidence
1. Safety Huddle bitesize sessions on the process of accessing Naloxone,
including out of hours, for stock replenishment for 2 weeks
Matron for Acute
Medicine
13/06/2025
Email
confirmation
2. Pharmacy to increase the stock level of Naloxone from 2 boxes to 3 on ward
8 North to reduce the likelihood of it not being immediately available. Ongoing
audits to ensure consistent stocking.
3. Update and distribute local guidelines on the management of opioid toxicity in
adult patients. (Interim advice will be shared based on current national best
practice guidelines.)
Principal Pharmacist -
Clinical Governance
and Medicines Safety
Principal Pharmacist -
Clinical Governance
and Medicines Safety
13/06/2025
Copy of audit
01/08/2025
Copy of
guideline
We will be sending a copy of this letter to North Central London Integrated Care Board.
If you would like any further information about any part of this letter, please do not hesitate to
contact us.
Yours sincerely,
Director of Nursing,
Royal Free Hospital
Royal Free London Group NHS Trust
Medical Director
Royal Free Hospital
Royal Free London Group NHS Trust
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