Rita Britten

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.

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.