Barts NHS Trust R
NHS / Health Body
Action Taken
The Trust reviewed decision-making between teams, reinforced documentation of significant decisions, reiterated consultant support availability to junior doctors, and instituted a rota for senior pharmacist support out-of-hours. (AI summary)
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Dear Ms Hassell
I am writing in response to the Prevention of Future Deaths report regarding the death of Keith Hill at the Royal London Hospital on 27 June 2019. There are three matters of concern:
When the plan changed and the transjugular liver biopsy became a percutaneous one, there was no communication between the interventional radiologist and the hepatologists. Even if it had not changed the plan, Mr Hill’s management would have benefited from a robust discussion between the specialists in these two fields, and an accurate record of the decision making.
This case has led to a review of how decisions are discussed and documented between the treating team and the interventional radiology team. There are regular and documentated discussions in the MDT meeting between the medical teams and the interventional radiologists; in addition there are conversations between referring teams and the interventional radiologists if non-elective patients are being treated without having been through a formal MDTdiscussion. In this context it is agreed between all clinical teams that at the time of the procedure the interventional radiologists will decide as to how to proceed based on their clinical knowledge, experience and the clinical situation at that point. Further conversations with the referring team at this point and in this case would not have changed the procedure performed. However, if the planned procedure proves impossible, or by the time the patient arrives in the IR theatre the patient has had a significant change in condition, the radiologist would contact the referring team. All significant decisions should be documented in the patient record. The importance of this has been reinforced. Royal London Hospital Room 007 Floor 10 South Tower
Mr Hill’s medical records were at times inadequate. The microbiologists thought that the junior hepatologists were making a record and vice versa. In the event, neither did. Most specifically, following the repeated advice of the microbiologists, the decision to change the plan and to prescribe micafungin on 25 June was not documented, it was simply written up on the prescription chart.
Note keeping has been reviewed by the consultant body and there has been agreement that the quality of note keeping must always meet the standards of best practice. There will be regular audits of note keeping at the monthly M&M meeting to drive and maintain improvement.
The junior pharmacist charged with dispensing the micafungin on the evening of 25 June recognised its toxicity to the liver and could not see from the medical record that Mr Hill’s liver function tests and hepatitis had been taken into account in the prescription. The last relevant entry in the medical record indicated that the micafungin should be held off. He sought senior guidance. However, there was no specialist hepatology pharmacist on the list of available contacts. Recognising he was outside his expertise, he contacted an intensive care specialist pharmacist, the on call microbiologist and the medical doctor looking after Mr Hill. However, no decision was made regarding the micafungin and so it was simply not given. A professor of hepatology was on call and knew Mr Hill’s situation well, but he was not contacted by the ward doctor (or by the microbiologist or a senior pharmacist). Despite improvements to the availability of senior pharmacists on call at the Royal London Hospital, concern remains about night time care and proper scrutiny of prescriptions. Junior medical staff do not appear to be sufficiently supported in this.
Following this case, the hepatology team have reiterated to the junior doctors on the team the availability of consultant support and have ensured that the switchboard contact details and ward 'white board' is up to-date. This will also be repeated during the induction training of new medical juniors and the consultants are stressing to their trainees the importance of escalation.
Since October 2019, the Pharmacy Department has instituted a positive change in the out of hours clinical support provided to junior pharmacists on-call.There is now a published rota, where each evening there is an accountable senior pharmacist off-site who is available to discuss and provide advice and resolution for any complex patients or issues. This includes advising on the need for specialist clinical advice and escalating where necessary. This support ensures our junior pharmacists and patients benefit from expert senior clinical pharmacy advice out of hours as well as during the normal working day. Pharmacists have reported in their monthly meetings that they now feel very well supported and having a named point of contact out of hours provides much needed discussion and advice when necessary.
I am writing in response to the Prevention of Future Deaths report regarding the death of Keith Hill at the Royal London Hospital on 27 June 2019. There are three matters of concern:
When the plan changed and the transjugular liver biopsy became a percutaneous one, there was no communication between the interventional radiologist and the hepatologists. Even if it had not changed the plan, Mr Hill’s management would have benefited from a robust discussion between the specialists in these two fields, and an accurate record of the decision making.
This case has led to a review of how decisions are discussed and documented between the treating team and the interventional radiology team. There are regular and documentated discussions in the MDT meeting between the medical teams and the interventional radiologists; in addition there are conversations between referring teams and the interventional radiologists if non-elective patients are being treated without having been through a formal MDTdiscussion. In this context it is agreed between all clinical teams that at the time of the procedure the interventional radiologists will decide as to how to proceed based on their clinical knowledge, experience and the clinical situation at that point. Further conversations with the referring team at this point and in this case would not have changed the procedure performed. However, if the planned procedure proves impossible, or by the time the patient arrives in the IR theatre the patient has had a significant change in condition, the radiologist would contact the referring team. All significant decisions should be documented in the patient record. The importance of this has been reinforced. Royal London Hospital Room 007 Floor 10 South Tower
Mr Hill’s medical records were at times inadequate. The microbiologists thought that the junior hepatologists were making a record and vice versa. In the event, neither did. Most specifically, following the repeated advice of the microbiologists, the decision to change the plan and to prescribe micafungin on 25 June was not documented, it was simply written up on the prescription chart.
Note keeping has been reviewed by the consultant body and there has been agreement that the quality of note keeping must always meet the standards of best practice. There will be regular audits of note keeping at the monthly M&M meeting to drive and maintain improvement.
The junior pharmacist charged with dispensing the micafungin on the evening of 25 June recognised its toxicity to the liver and could not see from the medical record that Mr Hill’s liver function tests and hepatitis had been taken into account in the prescription. The last relevant entry in the medical record indicated that the micafungin should be held off. He sought senior guidance. However, there was no specialist hepatology pharmacist on the list of available contacts. Recognising he was outside his expertise, he contacted an intensive care specialist pharmacist, the on call microbiologist and the medical doctor looking after Mr Hill. However, no decision was made regarding the micafungin and so it was simply not given. A professor of hepatology was on call and knew Mr Hill’s situation well, but he was not contacted by the ward doctor (or by the microbiologist or a senior pharmacist). Despite improvements to the availability of senior pharmacists on call at the Royal London Hospital, concern remains about night time care and proper scrutiny of prescriptions. Junior medical staff do not appear to be sufficiently supported in this.
Following this case, the hepatology team have reiterated to the junior doctors on the team the availability of consultant support and have ensured that the switchboard contact details and ward 'white board' is up to-date. This will also be repeated during the induction training of new medical juniors and the consultants are stressing to their trainees the importance of escalation.
Since October 2019, the Pharmacy Department has instituted a positive change in the out of hours clinical support provided to junior pharmacists on-call.There is now a published rota, where each evening there is an accountable senior pharmacist off-site who is available to discuss and provide advice and resolution for any complex patients or issues. This includes advising on the need for specialist clinical advice and escalating where necessary. This support ensures our junior pharmacists and patients benefit from expert senior clinical pharmacy advice out of hours as well as during the normal working day. Pharmacists have reported in their monthly meetings that they now feel very well supported and having a named point of contact out of hours provides much needed discussion and advice when necessary.