Source · Prevention of Future Deaths

Rita Britten

Ref: 2022-0162 Coroner: John Broadbridge Area: West Yorkshire Western 2 responses identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner identified a lack of clear national emergency guidelines for managing choking incidents in overweight or obese individuals where conventional abdominal thrusts are ineffective. The report suggests reviewing alternative techniques, such as inversion, and specialist equipment for these circumstances.

56-day deadline 8 Jul 2022 stated in the report

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner identified a lack of clear national emergency guidelines for managing choking incidents in overweight or obese individuals where conventional abdominal thrusts are ineffective. The report suggests reviewing alternative techniques, such as inversion, and specialist equipment for these circumstances.

View full coroner's concerns

The concern is of want of clear guidance on the steps to be taken to most effectively rescue the individual from the urgent and developing choking emergency when that individual does not conform to the competent adult to whom conventional abdominal thrusts are possible or might be effectively applied. In particular, this concern relates to but is not limited to the overweight/obese/bariatric individual (however that may be best described). a) There should be clear national emergency /resuscitation guidelines for dealing effectively with choking incidents where the individual is overweight/obese or otherwise where “conventional abdominal thrusts” are not possible or are less able to be effectively applied. In Mrs Britten’s case a significant element of early rescue techniques was compromised. It is perceived this will be an increasing present and future risk in the UK population due to obesity. b) There should be early review and assessment of papers that discuss the efficacy (or otherwise) in such circumstances of “inversion” of the affected choking individual said to be set out in: Hubert Blaine et al in American Journal of Medicine ref, Am J Med 2010 Dec; 123 (12) And “Effect of body position on relieve of foreign body from the airway”, Artur Luczak AIMS Public Health 6(2): 154-159 And how this or similar technique(s) might have application in the Hospital/clinical setting in which this choking episode occurred. c) There should be identified and assessed any specialist equipment to assist in these circumstances.

Responses

2 respondents

NHS England

NHS / Health Body

Letter dated 5 Aug 2022 PDF

AI-classified response stance Action Taken

AI-generated response summary

• NHS England stated that the Resuscitation Council UK had addressed the concerns raised in the report. • NHS England brought the matters of concern to the attention of its National Patient Safety Team to support general work on safety and quality of care.

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Dear Mr Broadbridge

Re: Regulation 28 Report to Prevent Future Deaths – Rita Britten who died on 29 July 2018.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 13 May 2022 concerning the death of Rita Britten on 29 July 2018. I would like to express my deep condolences to Rita’s family.

I note the inquest concluded Rita’s death was a direct result of a choking incident on 26 July 2018.

Following the inquest, you raised concerns in your Report that there should be clear national emergency/resuscitation guidelines for dealing effectively with choking incidents where the individual is overweight/obese or otherwise where “conventional abdominal thrusts” are not possible or are less able to be effectively applied. You stated that there should be early review and assessment of papers that discuss the efficacy in such circumstances of “inversion” of the affected choking individual and how this or similar techniques might have application in the hospital/clinical setting in which this choking episode occurred. You have added that there should be specialist equipment to assist in these circumstances. I note that you also sent your Report to the Resuscitation Council UK and I have had sight of their response. I am assured that Resuscitation Council UK have addressed all the concerns raised in your Report.

Although the circumstances surrounding this case are not specifically within NHS England’s sphere of statutory responsibility, I have brought the matters of concern to the attention of colleagues across our National Patient Safety Team (NPST) to support any general work around safety and quality of care in this area.

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 a Regulation 28 Working Group, comprising Regional Medical National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

05 August 2022

Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths 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.

Resuscitation Council

Local Authority

Letter dated 27 Jun 2022 PDF

AI-classified response stance Noted

AI-generated response summary

• The Resuscitation Council UK stated it would include a frequently asked question on its national website to highlight its position on managing choking in individuals where conventional abdominal thrusts are compromised. • The Resuscitation Council UK's guidelines recommend healthcare professionals use a laryngoscope and Magill’s forceps for foreign body removal, a technique taught in its advanced life support course. • The Resuscitation Council UK has assessed suction-based airway clearance devices and determined there is insufficient evidence to advocate for their routine use.

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Dear Sir, Re: Rita Britten, deceased Report to Prevent Further Deaths Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 Thank you for contacting Resuscitation Council UK in relation to your enquiries into the death of Rita Britten. We are sorry to learn of the circumstances leading to Mrs Britten’s death and would like to express our condolences to her family. Resuscitation Council UK exists to save lives by developing guidelines, inﬂuencing policy, delivering courses and supporting cutting-edge research related to cardiac arrest. Through education, training and research, we’re working towards the day when everyone in the country has the skills they need to save a life. We have considered the information provided in the Regulation 28 report and respond to your specific questions as set out below. a) There should be clear national emergency/resuscitation guidelines for dealing effectively with choking incidents where the individual is overweight/obese or otherwise where “conventional abdominal thrusts” are not possible or are less able to be effectively applied. In Mrs Britten’s case a significant element of early rescue techniques was compromised. It is perceived this will be an increasing present and future risk in the UK population due to obesity. Resuscitation Council UK sets outs its guidance for the management of foreign body airway obstruction ('choking') in our basic life support guidelines.1 These guidelines are drawn from the recommendations

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of the European Resuscitation Council2 and International Liaison Committee on Resuscitation3 based on a recent systematic review of published research.4

Guidelines need to balance the need for urgent and effective treatment of foreign body airway obstruction with the risks of harm (sometimes fatal) from the application of those interventions.4 They must also be easy to implement to enable early treatment of choking. Unfortunately even when attempted, the interventions will not always be successful and lead to survival in every case.

The guidelines support a step wise approach, starting with encouraging the person to cough, before progressing to back blows and abdominal thrusts. If these interventions are unsuccessful and the person becomes unconscious then chest compressions are recommended.

Chest compressions in the supine position (on their back) typically raise intrathoracic pressure to a greater extent than abdominal thrusts.5 They can be delivered irrespective of the persons size as it does not require the rescuer to encircle their arms around the person as is required for abdominal thrusts.

Figure showing how chest compressions are administered. The technique is feasible in persons with increased body mass index.

In preparing our guidance we considered the use of abdominal thrusts with the person lying on their back but decided not to include them given that chest compressions are probably more effective and our assessment that there is a higher risk life threatening abdominal injuries from the use of the abdominal thrust.

We will include a frequently asked question on our national website which highlights our position.

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b) There should be early review and assessment of papers that discuss the efficacy (or otherwise) in such circumstances of “inversion” of the affected choking individual said to be set out in Hubert Blaine et al in American Journal of Medicine ref, Am J Med 2010 Dec; 123 (12) And “Effect of body position on relieve of foreign body from the airway”, Artur Luczak AIMS Public Health 6(2):154-159

The European Resuscitation Council guidelines, upon which the UK guidelines are based, reviewed the role of these techniques which have been variously described as a chair/table manoeuvre. The view from the expert writing group was that these interventions lack sufficient evidence for their introduction into the guidelines at the present time. Resuscitation Council UK shares a similar view and also highlights concerns in relation to the safe manual handling of larger persons using these techniques which pose risks of injury to both patient and rescuer. As set out above, our view is that if abdominal thrusts are unsuccessful or cannot be administered, the rescuer should progress to chest compressions.

c) There should be identified and assessed any specialist equipment to assist in these circumstances.

Our guidelines recommend that healthcare professionals use a laryngoscope (a device put in the mouth with a light on the end) and Magill’s forceps (like pincers) to remove the foreign body under direct vision. Our recommendations are informed by our experience as well as published evidence demonstrating this can be an effective technique.4

The use of this technique is specifically taught in our advanced life support course (Cardiac Arrest Simulation Teaching Scenario 4).

Our quality standards for mental health inpatient care include the recommendations that this equipment is immediately available

equipment-and-drug

We have also assessed the evidence for suction-based airway clearance devices but consider there is insufficient evidence currently about either their safety or effectiveness, to advocate for their routine use. This view is aligned with the 2022 Evidence update on this topic from the International Liaison Committee on Resuscitation.

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We hope that the information contained in our response has been helpful. Please do not hesitate to contact us if you have any further questions.

Report sections

Investigation and inquest

On First October 2018 I commenced an investigation into the death of Rita Giulianna Nicola BRITTEN (“Mrs Britten”) aged 54. The investigation concluded at the end of the Jury inquest begun on 9 May ending on 13 May 2022. The jury recorded “Mrs Rita Britten died at Pinderfields Hospital on 29 July 2018 after life support was withdrawn. This was a direct result of a choking incident on 26 July at the Priestly Unit” The conclusion of the Jury as to the medical cause of death was: “I a Hypoxic Brain Injury I b Cardiac Arrest I c Upper Airway Obstruction Secondary to Food Bolus (choking) II “ Their Conclusion was expressed in the form of a questionnaire which is attached to this Report but the Jury included the words at Part 4 of their Record of Inquest: “-lack of communication/insufficient handover between staff
-System shortfalls in recording updating and accessing key information
-Risk assessments incomplete
-Inadequate first aid training”

Circumstances of the death

Mrs Britten was a detained patient under s3 MHA 1983. She choked while trying to bite off and swallow pieces of fresh apple. Despite efforts at rescue and resuscitation on the Ward where she was detained, she died later in Hospital without regaining consciousness from the effects of occlusion of airway.

She was 15 stone or so in weight with a BMI last assessed at 31 (“obese”) Abdominal thrusts otherwise “Heimlich Manouevre” (“conventional abdominal thrusts”)(after backslaps) to assist in ejection of material were indicated to be difficult if not impossible because of her body shape/size. An unusual manoeuvre of inversion of her body over the upright of an upholstered chair was also attempted; all attempts met with limited ejection of material from the airway. A larger piece of apple was eventually removed by forceps used by an attendant ambulance operative before adrenaline created ROSC but GCS was at 3/15 en route on pre alert emergency to Hospital, despite increase in her respiratory effort, and remained so.

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Report details

Reference: 2022-0162
Coroner: John Broadbridge
Coroner area: West Yorkshire Western

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: 8 Jul 2022 (stated in the report).

Sent to

NHS England

Resuscitation Council UK

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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