Department of Health and Social Care
Central Government
Noted
The Department acknowledges the concerns, states that NHS England engaged with the Trust, and that the CQC did not identify a need for further investigation of this specific case but continues to monitor the Trust’s performance. (AI summary)
View full response
Dear Ms Mutch,
Thank you for your Regulation 28 report to prevent future deaths of 4 August 2022 about the death of Mr Malcolm John Garrett. I am replying as Minister with responsibility for Health and Secondary Care. Please accept my sincere apologies for the significant delay in responding to this matter.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Garrett’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
The report raises concerns over:
(i) The Inquest heard that it was recognised that Mr Garrett was at high risk of acquiring COVID-19 in a hospital setting as he was immunosuppressed following his transplant. Despite the risk being recognised he still acquired COVID-19. The inquest heard that all such patients are at high risk in an acute hospital setting but there is no specific guidance for their management; (ii) The evidence before the inquest was that Mr Garratt needed to be discharged as quickly as possible to reduce the risk of acquiring COVID-19. However there was no specific guidance about expediting patients such as him and looking at alternative methods of treatment; (iii) Mr Garratt’s discharge was delayed in part due to opiate toxicity. That arose as a consequence of his kidneys not functioning correctly. The inquest heard evidence that to avoid opiate toxicity in such situations there needs to be a greater use of and understanding of the importance of monitoring kidney function.
In preparing this response, Departmental officials have made enquiries with NHS England, the Care Quality Commission (CQC) and the UK Health Security Agency (UKHSA).
You may wish to note that during the COVID-19 pandemic, extensive clinical guidance was issued by the NHS (eg. Coronavirus (england.nhs.uk) as well as by the National Institute for Health and Care Excellence (NICE), see Overview | COVID- 19 rapid guideline: managing COVID-19 | Guidance | NICE. More broadly, UKHSA also issued guidance in relation to patient discharge and infection prevention and control in health and care settings.1.
With regard to the issue relating to opiate toxicity and the need to understand the importance of monitoring kidney function. There is general guidance in the British National Formulary (BNF) in terms of ‘Prescribing in renal impairment’ and every opiate listed in the BNF will have an entry in relation to renal impairment eg codeine and morphine both state “Avoid use or reduce dose; opioid effects increased and prolonged or increased cerebral sensitivity occurs”.
The CQC advised that the matters of concern in this case, namely, hospital acquired COVID-19 and deaths attributed to a failure in monitoring kidney function are subject to regular reporting and/or evaluation as part of CQC’s monitoring and engagement activity. A management review meeting held in August 2022 concluded that neither concern was reflected in the monitoring data CQC held in relation to this Trust, such as being an outlier for the management of kidney injury. The Trust was asked at the time to provide any records or investigation reports relating to the death which the CQC would consider as part of its ongoing monitoring and engagement to ensure patients receive safe care and treatment.
The CQC subsequently followed up on this case with the Trust. They advised that the Trust provided sufficient assurance that they followed national guidance to try to minimise the likelihood of hospital acquired COVID-19, and to discharge medically optimised patients as quickly as possible against the backdrop of the limited social care availability during the pandemic. The CQC also received assurance from the Trust that they had identified learning and actions in response to complaints and inquest findings in relation to the clinical management of Mr Garrett’s kidney function. Due to these assurances, the CQC did not identify a need for further investigation of this specific case. However, the CQC continues to monitor the Trust’s performance in relation to hospital acquired infections, discharges and learning from incidents as part of its ongoing monitoring and engagement.
NHS England also engaged with the Trust and advised that the Trust has a process in place to manage and reduce the risks of patients in vulnerable groups. They further advised that the Trust has shared the learning from this incident and that it has continued to focus on patient discharge.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
1 [Withdrawn] Stepdown of infection control precautions and discharging COVID-19 patients and asymptomatic SARS-CoV-2 infected patients - GOV.UK (www.gov.uk)
Thank you for your Regulation 28 report to prevent future deaths of 4 August 2022 about the death of Mr Malcolm John Garrett. I am replying as Minister with responsibility for Health and Secondary Care. Please accept my sincere apologies for the significant delay in responding to this matter.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Garrett’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
The report raises concerns over:
(i) The Inquest heard that it was recognised that Mr Garrett was at high risk of acquiring COVID-19 in a hospital setting as he was immunosuppressed following his transplant. Despite the risk being recognised he still acquired COVID-19. The inquest heard that all such patients are at high risk in an acute hospital setting but there is no specific guidance for their management; (ii) The evidence before the inquest was that Mr Garratt needed to be discharged as quickly as possible to reduce the risk of acquiring COVID-19. However there was no specific guidance about expediting patients such as him and looking at alternative methods of treatment; (iii) Mr Garratt’s discharge was delayed in part due to opiate toxicity. That arose as a consequence of his kidneys not functioning correctly. The inquest heard evidence that to avoid opiate toxicity in such situations there needs to be a greater use of and understanding of the importance of monitoring kidney function.
In preparing this response, Departmental officials have made enquiries with NHS England, the Care Quality Commission (CQC) and the UK Health Security Agency (UKHSA).
You may wish to note that during the COVID-19 pandemic, extensive clinical guidance was issued by the NHS (eg. Coronavirus (england.nhs.uk) as well as by the National Institute for Health and Care Excellence (NICE), see Overview | COVID- 19 rapid guideline: managing COVID-19 | Guidance | NICE. More broadly, UKHSA also issued guidance in relation to patient discharge and infection prevention and control in health and care settings.1.
With regard to the issue relating to opiate toxicity and the need to understand the importance of monitoring kidney function. There is general guidance in the British National Formulary (BNF) in terms of ‘Prescribing in renal impairment’ and every opiate listed in the BNF will have an entry in relation to renal impairment eg codeine and morphine both state “Avoid use or reduce dose; opioid effects increased and prolonged or increased cerebral sensitivity occurs”.
The CQC advised that the matters of concern in this case, namely, hospital acquired COVID-19 and deaths attributed to a failure in monitoring kidney function are subject to regular reporting and/or evaluation as part of CQC’s monitoring and engagement activity. A management review meeting held in August 2022 concluded that neither concern was reflected in the monitoring data CQC held in relation to this Trust, such as being an outlier for the management of kidney injury. The Trust was asked at the time to provide any records or investigation reports relating to the death which the CQC would consider as part of its ongoing monitoring and engagement to ensure patients receive safe care and treatment.
The CQC subsequently followed up on this case with the Trust. They advised that the Trust provided sufficient assurance that they followed national guidance to try to minimise the likelihood of hospital acquired COVID-19, and to discharge medically optimised patients as quickly as possible against the backdrop of the limited social care availability during the pandemic. The CQC also received assurance from the Trust that they had identified learning and actions in response to complaints and inquest findings in relation to the clinical management of Mr Garrett’s kidney function. Due to these assurances, the CQC did not identify a need for further investigation of this specific case. However, the CQC continues to monitor the Trust’s performance in relation to hospital acquired infections, discharges and learning from incidents as part of its ongoing monitoring and engagement.
NHS England also engaged with the Trust and advised that the Trust has a process in place to manage and reduce the risks of patients in vulnerable groups. They further advised that the Trust has shared the learning from this incident and that it has continued to focus on patient discharge.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
1 [Withdrawn] Stepdown of infection control precautions and discharging COVID-19 patients and asymptomatic SARS-CoV-2 infected patients - GOV.UK (www.gov.uk)