Source · Prevention of Future Deaths

Malcolm Rathmell

Ref: 2019-0059 Date: 20 Feb 2019 Coroner: Jane Gillespie Area: Nottinghamshire Responses identified: 2 / 1 View PDF

Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based pharmacy review, with proposed actions still in infancy.

Date 20 Feb 2019

56-day deadline 1 Aug 2019 est.

Responses identified 2 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based pharmacy review, with proposed actions still in infancy.

View full coroner's concerns

(1) Mr Rathmell was treated and reviewed by a number of medical professionals from various disciplines between 14.03.18 and 22.03.18. No one identified during that time that he was being prescribed warfarin incorrectly.

(2) It has not been possible to identify when Patient B’s anti-coagulation chart was labeled with Mr Rathmell’s details, save that it is likely, on the balance of probabilities, that it took place on ward B3 between 1.30pm on 15.03.18 and 4.06am on 16.03.18.

(3) It has not been possible to establish how or why this happened despite an extensive investigation by the Trust and a detailed enquiry during the inquest.

(4) There was no ward based pharmacy review between 15.03.18 and 22.03.18.

(5) The proposed actions being considered by the Trust to address the issue of incorrect prescribing are in their infancy and other than sharing the learning from the SI report, no other changes or action has been implemented to address the risk of future deaths.

Responses

2 respondents

North East London NHS Foundation Trust NHS / Health Body

7 Apr 2021 PDF

Action Planned

North East London NHS Foundation Trust will provide record keeping training to staff, develop and implement a discharge checklist, conduct audits, update the HTT Service Operational procedure, and update the Trust’s Clinical Handover of Care and Discharge Policy. (AI summary)

View full response

Dear Mr Irvine,

Re: Inquest touching upon the death of Steven Paul Gary Stout

I refer to your letter dated 3 March 2021 and the enclosed Regulation 28 report issued in respect of your concerns regarding record keeping and the referral to Home Treatment Team (HTT), from Turner Ward at Goodmayes Hospital.

The Trust has taken into consideration concerns highlighted in the Regulation 28 report and agreed to take a number of actions to address your concerns. This includes:

 Provision of record keeping training to staff on Turner Ward to ensure that staff are reminded about the Trust’s expectations in respect of the record keeping.  Development and implementation of a discharge checklist to ensure that the discharge procedure safeguards patients’ clinical needs more robustly and supports healthcare staff.  Audits to monitor implementation of the discharge checklist.  Update of the HTT Service Operational procedure to ensure that the patients are not discharged without HTT or ACAT assessment, in the cases where there is a suggestion that the patients may benefit from HTT service input.  Update to Trust’s Clinical Handover of Care and Discharge Policy to ensure that the discharges take place more safely and effectively, and the referrals have been effectively completed to address the clinical needs of the patient as required.

Please find enclosed Trust’s action plan for further detail.

I wish to assure you that learning from incidents is a priority for the Trust and I am very grateful for your contribution to the improvement of our services, by way of raising your concerns to me.

Chair: Chief Executive:

I hope that the enclosed action plan provides reassurance to you that the Trust has taken this sad incident very seriously and that it reflects our commitment to improve care quality and patient safety. If you have any further queries, please contact my office on

Department of Health and Social Care Central Government

27 May 2021 PDF

Noted

The Department of Health and Social Care expresses sympathy and states that they expect the North East London NHS Foundation Trust to look carefully at the care provided and take actions to improve care. They outline national actions being taken to support people with severe mental illnesses and prevent suicide. (AI summary)

View full response

Dear Mr Irvine

Thank you for your letter of 3 March 2021 about the death of Steven Stout. I am replying as Minister with responsibility for mental health services and I am grateful for the additional time in which to do so.

To begin, I would like to say how very saddened I was to read the circumstances of Mr Stout’s death and I would like to offer my most heartfelt sympathies to his family and loved ones. It is so desperately sad to lose a loved one and to do so in circumstances where there is concern about the care they received must be particularly devastating.

We must do all we can to take learnings from Mr Stout’s death and, in light of your concerns, I expect the North East London NHS Foundation Trust to look carefully at the care provided to Mr Stout and to take the actions needed to improve the care of mentally-ill patients and prevent future deaths.

It is important that NHS organisations keep accurate medical records from admission and discharge and ensure that they are accessible to those involved in an individual’s care as is appropriate.

More generally, I would like to assure you that we continue to take action nationally to support people with severe mental illnesses and to prevent suicide and self-harm.

The NHS Long Term Plan and NHS Mental Health Implementation Plan 2019/20 – 2023/24, commits to new and integrated models of care between crisis, acute, primary and community services. These new and integrated models aim to ensure that people with severe mental illnesses can access the right level of support, advice and guidance wherever they present in the system. This includes providing care and support for people with co-existing substance use needs.

On 27 March 2021, we published our COVID-19 mental health and wellbeing recovery action plan, backed by £500million to support people’s mental health in 2021/22.

£58million of this will be used to accelerate the roll-out of the community mental health framework to treat adults and older adults with serious mental illness, including. This includes bringing forward the expansion of integrated primary and secondary care for adults and older adults with serious mental illness; embedding mental health practitioner roles in Primary Care Networks across the country to better meet the needs of people living with severe mental illnesses in primary care; and, expanding peer support and non- clinical workforce to boost the capacity of community mental health services.

The recovery action plan also includes £6million funding to boost support for specific suicide prevention work. £1million will bolster NHS England and NHS Improvement’s work on suicide prevention and £5million is being made available to support voluntary sector organisations that prevent suicide in the community. This extra funding is in addition to the £57million investment for suicide prevention through the NHS Long Term Plan between 2019/20 and 202324, which will see investment in all areas of the country to support local suicide prevention plans and establish suicide bereavement support services.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

NADINE DORRIES

MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH

Report sections

Investigation and inquest

On 03.10.2018 I commenced an investigation into the death of Malcolm John Lupton Rathmell, aged 79. The investigation concluded at the end of the inquest on 08.02.19. The conclusion of the inquest was a narrative conclusion;

On the 2nd day of April 2018 Malcolm Rathmell died of bronchopneumonia developed as a result of a prolonged period of immobility. This was the result of a hip fracture sustained two days prior to Mr Rathmell’s admission to the Queens Medical Centre on 14th March 2018, which was not diagnosed until 20th March 2018. Whilst in hospital Mr Rathmell was incorrectly prescribed warfarin on 4 or 5 occasions between 14th and 20th March 2018 when another’s patient’s anti-coagulation chart was incorrectly labelled with Mr Rathmell’s name. This led to a significant retroperitoneal bleed which contributed to Mr Rathmell’s death at the Queens Medical Centre, together with his past medical history of chronic kidney disease and hypertensive heart disease.

Circumstances of the death

Malcolm Rathmell was admitted to the Emergency Department at Queens Medical Centre on 14.03.18 following a fall at home two days previously. He was complaining of right hip pain. He was transferred to ward B3 at approximately 9.30pm the same day. An x-ray of his hip and chest had not revealed any fracture and the working diagnosis was a collapse of unknown cause and muscular pain. In the days that followed, it was considered that Mr Rathmell’s pain was disproportionate to the diagnosis and he was sent for an MRI which was delayed. On 20.03.18 it was confirmed that he had a fracture of the right pubis and right inferior pubic ramis. Also on ward B3 was another patient, who will be referred to as Patient B. Patient B had been admitted due to acute delirium and had a history of atrial fibrillation. He required warfarin and an anti-coagulation chart had been created for Patient B. At some point after Patient B’s chart was created at 10.10pm on 14.03.18, the chart was labelled with Mr Rathmell’s name and details. As a result, between 14.03.18 and 20.03.18 Mr Rathmell incorrectly and unnecessarily received 4 or 5 doses of warfarin. This was not identified by any of the multi-disciplinary team involved with Mr Rathmell until a pharmacy check on 22.03.18 revealed the mistake. Mr Rathmell started to suffer from retro-peritoneal bleeds on 25.03.18 and this continued until 27.03.18. Mr Rathmell passed away on 02.04.18. The cause of death was: 1a. Bronchopneumonia 1b. Pelvic fracture 2 Chronic kidney disease, hypertensive heart disease, retroperitoneal haemorrhage , Pathologist gave oral evidence and stated that he could find no origin for the bleed during the post mortem examination, and the haemorrhage was therefore likely spontaneous, due to a rupture without evidence of trauma and therefore, on the balance of probabilities, this indicated that the bleed was due to the warfarin treatment. I found, therefore, that the unnecessary warfarin treatment contributed to Mr Rathmell’s death.

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Shared signals

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Report details

Reference: 2019-0059
Date of report: 20 February 2019
Coroner: Jane Gillespie
Coroner area: Nottinghamshire

Responses identified

Responses identified 2 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Aug 2019 (estimated).

Sent to

Nottinghamshire University Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.