Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0170, written 4 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Apr 2025 |
|---|---|
| Reference | 2025-0170 |
| Deceased | Jacqueline Green |
| Coroner | Emma Whitting |
| Coroner area | Bedfordshire and Luton |
| Category | Alcohol, drug and medication related deaths · 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 DEATHS THIS REPORT IS BEING SENT TO: 1 CEO Bedford Hospitals NHS Foundation Trust 1 CORONER I am Emma WHITTING, Senior Coroner for the coroner area of Bedfordshire and Luton Coroner Service 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 26 September 2023 I commenced an investigation into the death of Jacqueline GREEN aged 72. The investigation concluded at the end of the Inquest on 01 April 2025. The Narrative Conclusion of the Inquest was: The Deceased suffered from acute on chronic kidney impairment and kidney infection but died from paracetamol induced liver failure whilst being treated in hospital 4 CIRCUMSTANCES OF THE DEATH At around lunchtime on 29 August 2023, the Deceased was admitted by ambulance to Bedford Hospital, having been found on her bedroom floor. She had reported to her carer that she had been there since falling in her dining room and crawling to her bedroom two days previously. She was described by the attending paramedics as being very weak, very slim and frail. In the Accident and Emergency Department, it was noted she was cachectic and dehydrated but her liver function tests were normal. She was admitted to a ward later that evening. Her weight was not taken prior to nursing staff asking a night junior doctor (who had not seen her nor had access to her records) at around 23.37 hours, to prescribe her with paracetamol. As the doctor was unaware that she weighed less than 50 kg, she was prescribed 1,000 mg of paracetamol to be taken 4 times daily. Although nursing staff estimated her weight at 44 kg the following day, and her actual weight was confirmed to be 33.6kg sometime on 31 August 2023, she continued to receive the prescribed dose of paracetamol until the evening of 31 August 2023, when the last dose was withheld by nursing staff. The reason for the withholding of the last dose of paracetamol on 31 August 2023 remained unclear. At around 11.20 hours on 1 September 2023, she suffered an episode of coffee ground vomiting. She continued to receive a further dose of paracetamol at 11.48 hours on 1 September 2023 but at the lower level of 500 mg. The reason for the reduced dose was also not clear. Following receipt of blood test results at 13:28 hours on 1 September 2023, which showed a significant derangement in her liver function, the administration of paracetamol ceased, and she was treated for paracetamol induced liver injury. Despite treatment, her condition deteriorated and as she was not a candidate for a liver transplant or intensive care treatment, she was placed on end-of-life care. She passed away at the hospital on 3 September 2023; her death being confirmed at 22.12 hours. Post-mortem examination confirmed that, whilst her fall and initial admission were due to acute on chronic kidney impairment and kidney infection, her immediate cause of death Regulation 28 – After Inquest Document Template Updated 30/07/2021 was liver failure. 5 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 the fact that the HSSIB made Safety Observations to mitigate the risks of unintentional paracetamol overdose in adult inpatients with low bodyweight in their National Report dated 24.02.2022 (https://www.hssib.org.uk/patient-safety- investigations/unintentional-overdse-of-paracetamol-in-adults-with-low- bodyweight/) none of these had been addressed/adopted at Bedford Hospital by the time of the Deceased’s admission on 29 August 2023 which meant that, despite weighing only 33.6kg, the Deceased was prescribed a daily dose of 1,000 mg x 4 which was only suitable for a patient weighing in excess of 50kg. 2. A lengthy PSII investigation (completed on 16 September 2024 and received by the Senior Coroner on 24 October 2024) delayed the hearing of the Inquest but also left unanswered questions. In particular, there was no explanation as to why the nursing staff, having estimated the Deceased’s weight at 44 kg the day after the paracetamol was prescribed (which although quite incorrect was still below the threshold for a prescription of that level) still proceeded to administer the prescribed dose yet did not administer the last dose on the night of 31 August 2023 and administered only ½ the prescribed dose the following morning. Further exploration of this with the relevant staff might well highlight additional safety concerns (for example, did nursing staff feel unable to challenge the prescription directly with the doctors?). 3. Despite the PSII report referencing the 2022 HSSIB report and recommending that this should be shared with staff, relevant Safety Observations made in the HSSIB Report appear to have been insufficiently addressed: (a) Although Bedford Hospitals NHS Trust are now using the Nervecentre electronic record system which, since 28th February 2024, has included the height and weight of patients and prevents a prescribing doctor from prescribing without a patient’s weight having first been entered, staff are still able to enter a estimated weight and there do not appear to be any alerts on this system to advise of the need for weight accuracy in the prescription of oral paracetamol and consideration of the risk of liver toxicity in those weighing under 50 kg (as advised in Safety Observation 02/2022/151); (b) Whilst the PSII report states as an Action that “Patients should be weighed on admission and the information documented”, other than the provision of a ‘pat slide’, no other practical actions are planned for actually achieving this outcome, particularly in respect of those adults at risk of an unintentional paracetamol overdose, such as an alert aimed at those administering medication as well as those prescribing it (as advised in Safety Observation 02/2022/151). 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by May 30, 2025. I, the coroner, may extend the period. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 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. 9 Dated: 04/04/2025 Emma WHITTING Senior Coroner for Bedfordshire and Luton Coroner Service Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
- Bedfordshire Hospitals NHS Foundation Trust Luton & Dunstable University Hospital : Lewsey Road Our ref Luton Bedfordshire LU4 0DZ Ms Whitting His Majesty’s Coroner’s Office T: 01582 491 166 The Court House Woburn Street Ampthill Bedfordshire CEO EA: P| MK45 2HX Date: 14" May 2025 Dear Ms Whitting Re: Jacqueline Green — Regulation 28 Report to Prevent Future Deaths Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 4 April 2025 concerning the death of Jacqueline Green on 3 September 2023. In advance of responding to the specific concerns raised in your Report, | would like to express my sincere condolences to Jacqueline’s family and loved ones. The Trust are keen to assure you and the family that your concerns raised through the Report have been listened to and reflected upon. | provide a summary of the matters of concern raised: 1. HSSIB report implementation at Bedford site - Despite the fact that the HSSIB made Safety Observations to mitigate the risks of unintentional paracetamol overdose in adult inpatients with low bodyweight none of these had been addressed/adopted at Bedford Hospital by the time of the Deceased’s admission on 29 August 2023 2. Nursing actions related to the event - unanswered questions and further exploration required from the PSII investigation, in particular, request for rationale on the administration of IV paracetamol via the nursing staff during the event and any additional safety concerns to be addressed as a result of this (for example, did nursing staff feel unable to challenge the prescription directly with the doctors?) 3. Optimisation of Nerve centre information regarding weight accuracy - Following Nervecentre implementation at Bedford Hospital staff are still able to enter an estimated weight and there do not appear to be any alerts on this system to advise of the need for weight accuracy in the prescription of oral Bedfordshire Hospitals incorporating: Bedford Hospital, Luton and Dunstable Hospital paracetamol and consideration of the risk of liver toxicity in those weighing under 50 kg (as advised in Safety Observation 02/2022/151); 4. Additional actions related to monitoring weight to reduce risk - Practical steps to achieve the outcome to reduce the risk of unintentional paracetamol overdoses (as advised in Safety Observation 02/2022/151) in addition to PSII report action “Patients should be weighed on admission and the information documented”, other than the provision of a ‘pat slide’ | have undertaken an investigation to respond to the matters of concern raised and to also identify whether there is any further learning for the Trust. 1. HSSIB report implementation at Bedford site A large amount of work has been undertaken following the HSSIB report, and as a result of Jaqueline’s death, to reduce incidences of paracetamol overdoses in patients with low bodyweight. This is an ongoing project to continue to look at areas where further improvement can be made. | provide a summary of the actions taken to date in response to the HSSIB report: e Apharmacy led QI project and audit conducted cross site led by the medication safety team and presented at the Medical Safety Committee in March 2025. This involved systemic sampling of 200 patients in order to collect data and the prescribing patterns for IV paracetamol. The audit findings were presented at the cross site ward manager and senior nursing meeting on 21 April 2025 and will be presented to the doctors at Grand Round in June 2025. e Apharmacy led review of stock allocations and IV paracetamol across both sites and memo produced to support switching to oral to promote prudent use of IV paracetamol e Asoft review of IV paracetamol after 24 hours has been introduced on Nervecentre. This will place a reminder prompt on Nervecentre for clinicians pharmacy and nursing teams to review any paracetamol prescription after 24 hours with the aim to reduce prolonged use of IV paracetamol and as a prompt to step down to oral (reducing patient exposure to risk associated with IV paracetamol). e HS report included in the Trust Medicines Information and Safety Tips Newsletter in September 2023 2. Nursing actions related to the event In order to address the question raised with the Report, | obtained a statement from the nurse who weighed Jacqueline and administered the dose of 500mg on 1% September. A further statement was requested from the nurse who withheld the dose on 31%! August but as they are not directly employed by the Trust | unfortunately have yet to receive this. Within the nurse’s statement, it helpfully clarifies that it was the medical registrar who, on 31% August, asked the nurse whether Jacqueline had been weighed after the IV prescription of 1g had been made. The same nurse had earlier that day administered the prescribed amount of 1g IV paracetamol. The doctor found a weight from earlier that year within the GP records and asked that the patient be weighed as soon as possible. The nurse was able to locate a hoist sling and weigh Jacqueline with the recorded weight of 33kg. The nurse made the decision to administer the lower dose of 500mg on 1° September as they had weighed the patient and had documented the weight of 33kg within the records. Within her statement, the nurse has acknowledged that further action should have been taken on 31% August to alert the medical staff of the need to amend the prescription. A handover should have also occurred when she ended her shift to ensure that the nurse who took over the care of Jacqueline was aware of the fact that Jacqueline was under 50kg and would need a reduced dose of IV paracetamol. With the introduction of the measures that | have outlined in my response to the Report, the risk of a similar situation occurring again has been mitigated against. 3. Optimisation of Nerve centre information regarding weight accuracy There is now a prompt when prescribing paracetamol (all routes) on EPMA that reminds prescribers of the need to ensure there is an accurate weight recorded and that the dose is appropriate. On all IV paracetamol dose sentences for adult patients, it now states ‘for IV use — dose as 15mg/kg’. The following message appears on all routes for paracetamol adult dose sentences stating ‘Ensure patient weight is recorded as risk of liver toxicity in patients who weigh less than 50kg’. These messages appears at the point of prescribing and administering. Any weight that is recorded on the system appears at the point of prescribing and administration with a date and time stamp. A Nervecentre paracetamol prescribing guide has been produced and been launched in to support safe prescribing of paracetamol. 4. Additional actions related to monitoring weight to reduce risk All wards have the equipment available to weigh patients on admission. As HSSIB points out in their report, there is more costly equipment available that could make the task easier for nursing staff but are outside of the Trust’s available financial resources at present. What the Trust are trialling is a live dashboard that shows the patient weight compliance for all wards across both hospital sites. Once completed it will be directed towards ward managers and matrons, who at any time will be able to see how many patients have been weighed on a particular ward. The data provided below is not accurate as the dashboard remains in development at present but the Trust hope that this will be completed before the end of 2025 and will appear as follows: Clinical Safety Dashboard - Patient Weight Compliance The data will be taken from the recorded weight on Nervecentre and if a patient has not been weighed within the target time of 6 hours it will reduce a particular wards compliance. As highlighted within the PSII report, the ward where this incident took place purchased a new pat slide to assist with the weighing of immobile patients. Whilst the purchasing of new equipment can assist in ensuring patients are weighed on admission to a ward, the Trust also recognises the need for there to be IT systems that can support in identifying where a patient has not been weighed and to alert clinical staff so that this can be rectified. This is the aim with the introduction of the dashboard. Thank you for bringing these important patient safety issues to my attention. | do hope my response provides some assurance to you and Jacqueline’s family regarding the actions being taken by the Trust in relation to the care provided to patients who require IV paracetamol but at a reduced amount due to being underweight. Yours sincerely Chief Executive Officer
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