Source · Prevention of Future Deaths

Nuliyati Businje

Ref: 2024-0441 Date: 23 Apr 2024 Coroner: Victoria Davies Area: Cheshire Responses identified: 2 / 2 View PDF

DVT risk assessment tools inadequately assess mobile or psychiatric patients, and clinicians lack awareness that observations can normalise despite a persistent clot, leading to missed diagnoses and increased VTE risk.

Date 23 Apr 2024

56-day deadline 7 Oct 2024 est.

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Despite evidence to suggest that mobility is not the ultimate deciding factor of risk of DVT , the risk assessment tool as currently drafted and relied upon by clinicians would suggest that there is no further need for assessment. This raises a risk of future deaths for those patients such as Ms Businje who were at risk of VTE, or those with cancer for example, but who do not have significnstly reduced mobility and would therefore fall outside of the risk assessment
2. Based on the evidence heard, patients on a psychiatric unit are at increased risk of DVT but this is not factored into the risk assessment, nor the NICE guidance: The latter guidance has a specific section for psychiatric patients but does not provide any specific information as to risk and directs the reader to the same Department of Health risk assessment tool:
3. Based on the evidence of the expert physician, a common presentation of a clot can be derangement in observations such as respiratory rate and heart rate, but these can normalise as the clot passes further on and the blockage eases: Iam concerned that this does not appear to be widely known, is not part of training at least in the Trust in this case due to the lack of awareness, and I am told is not something which is taught nationally. There is a risk that a clinician without this knowledge would, as in this case, be reassured by the improving observations and the clot, and risk of a further more serious clot, would be overlooked,

Responses

2 respondents

National Institute for Health and Care Excellence Other

18 Jun 2024 PDF

Noted

NICE acknowledges the concerns and explains its guideline on venous thromboembolism risk assessment, noting that it does not recommend a particular risk assessment tool and that clinicians should choose a tool that best fits the patient's clinical circumstances. (AI summary)

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Dear Ms Davies_ write in response to your regulation 28 report of 23 April 2024 regarding the very sad death of Ms Nuliyati Busunje. would Iike to express my sincere condolences to Ms Busunje's family. We have reflected on the circumstances surrounding to Ms Busunje's death and the concerns raised in your report With regard to the assessment of VTE risk in people with psychiatric disorders admitted to hospital, in the NICE guideline on yenous thromboembolism in over 6s: reducing the risk of hospital-acquired deep_vein thrombosis_r_pulmonary embolism we recommend that clinicians should use a tool published by a national UK body, professional network or peer-reviewed journal' to assess VTE risk, however we do not recommend a particular risk assessment tool as there is not enough evidence to support the use of one over another and during development of the guideline, the committee made a research recommendation in this area, reflecting the uncertainty in the evidence for one risk tool over another. The Department of Health's national risk assessment for VTE, highlighted in recommendation 1.9.1, been widely used in the NHS to assess a person's risk of VTE since 2010, however it has not been validated or tested against other tools to evaluate its diagnostic accuracy or effectiveness at correctly identifying people at risk of VTE_ As such, we explain that the tool is commonly used to develop a treatment plan for psychiatric patients. However, clinicians can and should choose a different tool if it better fits the clinical circumstances of the patient: Concerns regarding the risk assessment tool referenced in NG89 would need to be directed to the Department of Health and Social Care_ We agree that people with psychiatric disorders may be at risk of developing venous thromboembolism, particularly when acutely unwell and admitted to hospital, and that that risk assessment should not stop once significantly reduced mobility has been ruled out as other risk factors may be present: The committee recognised that the risk of VTE in these patients may be due to the presence of several risk factors including reduced mobility due to psychiatric illness or sedation, but also dehydration due to poor oral intake, or comorbid physical illness and this should be included in the risk assessment The committee also noted that as with other populations, prophylaxis decisions for NICE WWw nice org uk nice@nice org uk has

psychiatric inpatients should be clearly documented and they should be reassessed throughout their stay as it likely that their clinical condition could change unexpectedly: We believe that our recommendations for assessment and review cover the clinical circumstances outlined in your report: In NG89 we recommend that all people admitted to an acute psychiatric ward should be assessed for risk of VTE at consultant review or if their clinical condition changes (recommendation 1.9.2). Further, we recommend that clinicians should consider pharmacological VTE prophylaxis for people admitted to an acute psychiatric ward whose risk of VTE outweighs their risk of bleeding and that this should be continued until the person is no longer at risk (recommendations 1.9.3 and 1.9.5). We note the observations of the consultant physician regarding a growing body of research which indicates that psychiatric patients on a ward are at higher risk of DVT _ As discussed above, the risks pertaining to this population were discussed by the committee and is reflected in our recommendations We are aware of a recent retrospective study which showed no difference in the VTE rates following psychiatric inpatient admission compared to unselected acute medical admission. The signs and symptoms of a pulmonary embolus (PE) are discussed in the Clinical Knowledge Summary on Pulmonary Embolus_ This notes that the signs and symptoms of pulmonary embolism are non-specific, but symptoms typically have a sudden onset _ and that PE may be completely asymptomatic and be discovered incidentally when assessing for another condition. The recommendations on when to suspect PE is based on clinical features of PE described in the NICE and European Society of Cardiology (ESC) guidelines [NICE_2023; Konstantinides_2020] and the BMJ Best Practice [BMJ Best Practice_2022]: NICE recommends considering the Pulmonary embolism rule-out criteria (PERC) rule if clinical suspicion of PE is low, based on the overall clinical impression, and if other diagnoses are feasible_ However; given the non-specific nature of presenting symptoms, clinicians need to have a high level of suspicion in people with risk factors for PE. Again, offer my sincerest condolences to Ms Busunje's family.

Department of Health and Social Care Central Government

22 Jul 2024 PDF

Action Planned

The Department of Health and Social Care will work with NHS England to consider the VTE risk assessment tool, in light of the concerns raised. (AI summary)

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Dear Victoria,

I hope this response is helpful and demonstrates my sincere desire to improve care for patients so we can avoid such tragedies from occurring. Thank you for bringing these important concerns to my attention.

Report sections

Investigation and inquest

On 21 April 2017 I commenced an investigation into the death of Nuliyati BUSINJE aged 52 The investigation concluded at the end of the inquest on 18 April 2024. The conclusion of the inquest was that: Narrative Conclusion Nuliyati Businje died as a result of a massive pulmonary thromboembolism (clot) for which there were a number of factors: Fluid monitoring was inadequate and the lack of a plan to address this probably caused or contributed to death_ Nuliyati's lack of compliance for diabetes treatment and absence of a plan to address this possibly caused or contributed to her death. The plan and management from April onwards when Nuliyati's blood sugars were high and uncontrolled with the use of insulin, and when significant changes in her vital signs were seen, and a lack of referral, probably caused or contributed to her death

Circumstances of the death

Ms Businje was an inpatient on a psychiatric unit, sectioned under the Mental Health Act On admission, her VTE risk was assessed and, on the basis that her mobility was not significantly reduced from her baseline, she was deemed to be not at risk and no VTE prophylaxis was given. During her admission she was accepting only limited diet and fluids, and was refusing medication for her diabetes: days into her admission, her physical observations became abnormal (NEWS 7 which included a blood pressure which could not be obtained) and her blood sugar levels were high (2O+mmols). The on call doctor was called, who repeated her observations and found these to be normal (NEWS 0). Insulin was given but that evening her blood sugar continued to rise, resulting in an increased dose in insulin. On 10 of her admission, her blood sugar reading was over 33.lmmols and she subsequently suffered a cardiac arrest. post mortem examination found a massive pulmonary embolus, due to deep venous thrombosis Expert evidence was obtained from a consultant physician and he gave oral evidence in court_ He explained that Ms Businje had a number of risk factors for DVT , including dehydration, her age and obesity. In his view, the risk assessment should not have stopped once significantly reduced mobility was ruled out, as her other risk factors would necessitate the need for VTE prophylaxis: He was surprised when it was pointed out to him that the Department of Health VTE risk assessment tool in place then (2017) and still in place_now suggests_there is_no_need for _further assessment A consultant psychiatrist on Regulation 28 _ After Inquest Document Template Updated 30/07/2021 day The behalf of the Trust gave evidence that there is a growing body of research which indicates that psychiatric patients on a ward are also at higher risk of DVT and as such they have amended their local assessment tool to consider other factors over and above mobility _

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Report details

Reference: 2024-0441
Date of report: 23 April 2024
Coroner: Victoria Davies
Coroner area: Cheshire

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Oct 2024 (estimated).

Sent to

Department of Health and Social Care

National Institute for Health and Care Excellence

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.