Northern Care Alliance NHS Foundation Trust
NHS / Health Body
Action Taken
Northern Care Alliance has implemented consultant countersignatures on ward round outcomes, updated grand round and weekend handover proformas to include an ePMA review checkbox, and updated the junior doctors' handbook with information on tumour lysis syndrome. (AI summary)
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Dear Ms Robertson
Re: Inquest touching the death of Mr Mohammed Abdus Salam
I write further to the above matter following receipt of your Regulation 28 report dated 14th October 2021. This correspondence constitutes the Northern Care Alliance NHS Group response to that report.
I would like to emphasise that I fully support the use of Regulation 28 reports as an important mechanism for learning and that as an organisation we are continuously looking for ways to improve patient safety. I am therefore grateful to you for sharing your concerns that our investigation into the sad death of Mr Salam did not satisfactorily address the factors associated with the prescribed medication Rasburicase. We have reviewed our internal investigation, improved our learning, and agreed actions to prevent such recurrence in the future.
Our Haematology consultants have explained that Rasburicase may be prescribed either as a “stat” dose, in which case the need for further doses should be evaluated within 24 hours, or as a continuous course of treatment for a defined period of time. Review of the Grand Round notes pertaining to Mr Salam on 31 March 2021 shows a recommendation for a single 3mg dose of Rasburicase. There is no written plan for further doses. On the electronic prescribing system (ePMA) it was also prescribed as a “stat” dose with no follow- on instructions. The attending consultant’s intention had been for the drug to be given on a continuous basis. This discrepancy between the consultant’s intention and the written documentation demonstrates the need to ensure that our processes for clinical reviews and ward rounds are robust so that patient plans are well documented and consequently well communicated within the team.
Please see below the issues that we have identified and our plans to address them:
Issue: To ensure that clinical management plans are well recorded and communicated.
Action: The attending consultant will countersign the recorded outcome of ward rounds to verify the accuracy of the review and the management plan. This process has been implemented following communication to clinical colleagues on 6th December 2021.
Issue: Review of medications must be an integral part of ward rounds and patient reviews.
Action: Grand round and weekend handover proformas will be updated to include a check box and consultant countersignature to record that ePMA has been reviewed. This has been implemented following communication to clinical staff on 6th December 2021. I have taken the liberty of enclosing a copy of the updated proforma for assurance. Both the above remedial actions will be audited for compliance in 3 months’ time and added to the official departmental work programme which is monitored through the Cancer & Complex Medicine Governance Meeting
Issue: The RCA identified a lack of awareness of management of tumour lysis syndrome.
Action: The section on tumour lysis syndrome has been updated in our junior doctors’ handbook. We further plan to introduce a specific guideline for the management of tumour lysis syndrome and the use of Rasburicase to be available on the Trust Intranet. To be reviewed and approved at the Cancer & Complex Medicine Governance Meeting on 21st January 2022.
Issue: The need to ensuring robust address of any medication issues in all RCAs.
Action: Pharmacy input to the RCA will be mandatory whenever medication issues are identified to ensure objective and expert review. This has been communicated to Divisional Clinical Governance Managers and Divisional Leadership teams by the Medical Director
The actions detailed above will improve our clinical and governance processes and mitigate recurrence. We hope that we have addressed your concerns.
Re: Inquest touching the death of Mr Mohammed Abdus Salam
I write further to the above matter following receipt of your Regulation 28 report dated 14th October 2021. This correspondence constitutes the Northern Care Alliance NHS Group response to that report.
I would like to emphasise that I fully support the use of Regulation 28 reports as an important mechanism for learning and that as an organisation we are continuously looking for ways to improve patient safety. I am therefore grateful to you for sharing your concerns that our investigation into the sad death of Mr Salam did not satisfactorily address the factors associated with the prescribed medication Rasburicase. We have reviewed our internal investigation, improved our learning, and agreed actions to prevent such recurrence in the future.
Our Haematology consultants have explained that Rasburicase may be prescribed either as a “stat” dose, in which case the need for further doses should be evaluated within 24 hours, or as a continuous course of treatment for a defined period of time. Review of the Grand Round notes pertaining to Mr Salam on 31 March 2021 shows a recommendation for a single 3mg dose of Rasburicase. There is no written plan for further doses. On the electronic prescribing system (ePMA) it was also prescribed as a “stat” dose with no follow- on instructions. The attending consultant’s intention had been for the drug to be given on a continuous basis. This discrepancy between the consultant’s intention and the written documentation demonstrates the need to ensure that our processes for clinical reviews and ward rounds are robust so that patient plans are well documented and consequently well communicated within the team.
Please see below the issues that we have identified and our plans to address them:
Issue: To ensure that clinical management plans are well recorded and communicated.
Action: The attending consultant will countersign the recorded outcome of ward rounds to verify the accuracy of the review and the management plan. This process has been implemented following communication to clinical colleagues on 6th December 2021.
Issue: Review of medications must be an integral part of ward rounds and patient reviews.
Action: Grand round and weekend handover proformas will be updated to include a check box and consultant countersignature to record that ePMA has been reviewed. This has been implemented following communication to clinical staff on 6th December 2021. I have taken the liberty of enclosing a copy of the updated proforma for assurance. Both the above remedial actions will be audited for compliance in 3 months’ time and added to the official departmental work programme which is monitored through the Cancer & Complex Medicine Governance Meeting
Issue: The RCA identified a lack of awareness of management of tumour lysis syndrome.
Action: The section on tumour lysis syndrome has been updated in our junior doctors’ handbook. We further plan to introduce a specific guideline for the management of tumour lysis syndrome and the use of Rasburicase to be available on the Trust Intranet. To be reviewed and approved at the Cancer & Complex Medicine Governance Meeting on 21st January 2022.
Issue: The need to ensuring robust address of any medication issues in all RCAs.
Action: Pharmacy input to the RCA will be mandatory whenever medication issues are identified to ensure objective and expert review. This has been communicated to Divisional Clinical Governance Managers and Divisional Leadership teams by the Medical Director
The actions detailed above will improve our clinical and governance processes and mitigate recurrence. We hope that we have addressed your concerns.