Source · Prevention of Future Deaths

Pamela Hands

Ref: 2017-0373 Date: 18 Dec 2017 Coroner: Emma Carlyon Area: Cornwall and the Isles of Scilly Responses identified: 1 / 2 View PDF

A critical risk of respiratory depression in opioid-treated patients receiving nerve blocks was not widely recognised, and national monitoring guidelines were absent. This necessitates new guidelines and professional awareness.

Date 18 Dec 2017

56-day deadline 8 Apr 2018 est.

Responses identified 1 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

The Expert Consultant in Pain Medicine explained that after the fascia iliac block was administered analgesia will occur over 10-15 minutes. As the patient obtains better analgesia from the fascia iliac block, the opioids in the circulation would have a more toxic effect than an analgesic effect. Pain is a potential arousal stimulus keeping the patient awake and aware of their surroundings. Pain is also a respiratory stimulant; There is an intimate Iink between the neurophysiology of pain and the respiratory stimulant: It was recognised that removing a painful stimulus using a local anaesthetic block can pre-dispose patients who have had opioids to respiratory depression. The risk can be increased if the patient has other respiratory depressant risks such as alcohol which can act synergistically with the opioid. In order to avoid the patient would need to be observed during the first 30 minutes after the administration of the block to reverse the effect of the opioid or support the respiration if required to avoid a cardiac arrest and death; At the time of the death were no National Guidelines to advise on the need to monitor patients post procedure or application of the anaesthetic nerve block At inquest it was clear from the evidence of the Clinical Director of Emergency Medicine that in 2015 the effect of relative opioid toxicity following the administration of a local anaesthetic nerve block for proximal femur fractures was not widely recognised within Emergency Medicine_ As there was an increase in the use of fascia iliac block in conjunction with opioid analgesia in emergency medicine , this risk should be highlighted to health professionals so that were aware of the risk and the appropriate guidelines put in place.

Responses

1 respondent

British Orthopaedic Association

13 Feb 2018 PDF

Action Planned

The British Orthopaedic Association (BOA) intends to update its BOAST (BOA Standards for Trauma) document that covers the management of hip fractures to reflect and emphasise the need for appropriate monitoring of all patients, particularly those in pain pre or post procedure, within the next 12 months. (AI summary)

View full response

Dear Dr Carlyon,

Regulation 28: Report to prevent future deaths Re: Pamela Margaret Hands aka Horner

Thank you for your letter dated the 18th December, received by us in January and discussed at our monthly Executive Board Meeting. I apologise for the late arrival of our response.

The BOA recognises the importance of learning from past events and understands that the events in question which are relevant to our associations occurred in December 2015.

The BOA supports a multidisciplinary approach to the management of this group of vulnerable patients with a fracture of the femoral neck. We have advocated for and been actively involved in the development of a prompt MDT approach to the assessment and management of these patients, the development of dedicated trauma lists for patients with hip fractures, written standards for the management of such fractures and the instigation of a National Hip Fracture Database that monitors the process for and outcome of these patients. We feel that the care of this group of patients has improved significantly over recent years. Outcomes are discussed regularly at our annual national meeting as well as amongst our Specialist Societies (such as the Orthopaedic Trauma Society – OTS). Relevant updates are cascaded to our membership via regular emails to the members of our association.

We appreciate your recognition that a multidisciplinary team is involved in patient care but we note that you have only contacted the BOA and the Royal College of Emergency Medicine with respect to this incident. It is often the Anaesthetists and the Pain Team who are involved in the local guidelines for management of pain in patients (including post procedural pain) and the Nursing Staff who take prime responsibility for the monitoring of such patients following the administration of analgesic medication in any format. We feel that it important that your advice is distributed to all involved and we would like to suggest that you also seek input from the relevant bodies for nursing and anaesthesia, namely the RCN and the AAGBI.

contd…/

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On our part, we intend that our BOAST (BOA Standards for Trauma) document that covers the management of hip fractures will be updated to reflect and emphasise the need for appropriate monitoring of all patients particularly those in pain pre or post procedure. This document is due for renewal within the next 12months.  Should you feel that this letter does not cover all the issues that you are causing you concern, please do contact us again.

Report sections

Investigation and inquest

On the 9' December 2015, opened an investigation into the death of PAMELA MARGARET HANDS otherwise known as PAMELA MARGARET HORNER: An inquest was opened on 1th December and a full inquest hearing took place at Truro Municipal Building, Truro between the 11 July 2017_ The inquest concluded that the cause of death was Ia Multi Organ Failure 1b Cardiac Arrest (26.11.2015) 1c Effects of Relative Opiate Toxicity following administration of Local Anaesthetic Nerve Block for a Periprosthetic fracture of the femur due to a fall II Coronary Artery Atherosclerosis A Narrative Conclusion was reached "Pamela Margaret Hands died from multiple organ failure following a collapse in hospital Accident and Emergency Department on 26.11.15 due to the effects of relative opiate toxicity following the administration of a local anesthetic for necessary pain relief for a periprosthetic fracture due to a fall: The lack of adequate patient observations from the time of administration of the Local Anesthetic prevented the recognition of opioid toxicity and reversal of the opioid side effects with an antidote and or medical intervention to avoid the cardiac arrest'

Circumstances of the death

Pamela Hands fell in the kitchen at her home address;_ at just before 22.45 on 21st November 2015. She was transferred to the Royal Cornwall Hospital by ambulance during which time she was administered morphine sulphate for pain relief at 23.35 (5 mg) and 00.34 (2.5 mg): She was diagnosed with a periprosthetic fracture of femur: She was given a further dose of morphine sulphate between 1.20 30 am (10 mg) In order to assist the with relief a right fascia iliac block (40mls 2.5% bupivacaine) was administered intravenously at 2.20 am with no issues. At the time of the administration of the Local Anaesthetic and for 5-10 minutes after; there was no evidence of opioid toxicity. She was not adequately observed from around 2.30 am: At 2.53 am she was found unresponsive on the bed, not breathing and with no pulse. She was successfully resuscitated at 2.57 but despite this she never recovered consciousness and despite medical support died on 1 December 2015. The effects of the opioid toxicity following the administration of the local anesthetic nerve block for relief led to the respiratory and subsequence cardiac arrest: Opioid and Fascia iliac blocks are recognized as a standard care pathway in the peri-operative management of patient with neck of femur fractures. Observations after the administration of the fascia iliac block would on balance have recognized the opioid toxicity allowing the antidote (Naloxone) andlor other medical support to be administered and on balance the cardiac arrest avoided

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action: To increase awareness to health professionals within your organisation or in general of this risk so that the appropriate preventative measures, guidance and protocols are in place within organisations to reduce the risk of respiratory depression, arrest or death after the administration of fascia iliac block pain pain being this, they

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Report details

Reference: 2017-0373
Date of report: 18 December 2017
Coroner: Emma Carlyon
Coroner area: Cornwall and the Isles of Scilly

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Apr 2018 (estimated).

Sent to

Royal College of Emergency Medicine

Royal College of Surgeons

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.