Source · Prevention of Future Deaths

Peter Keep

Ref: 2016-0362 Date: 14 Oct 2016 Coroner: Karen Henderson Area: Surrey Responses identified: 1 / 1 View PDF

The hospital lacked a clear sedation policy for cardiac procedures, leading to inconsistent drug use, inadequate staff training on anxiolytics, and no action plan for patient intolerance or airway emergencies.

Date 14 Oct 2016

56-day deadline 23 Apr 2017 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Inappropriate use of sedation and a lack of a sedation policy for cardiac electrophysiological procedures _ An absence or a lack of knowledge of a Trust policy for safe sedation outside the operating theatre environment; which could therefore not be considered or implemented. An incoherent approach to sedation for procedures in the catheter Lab; with different clinicians using different drugs inconsistently e.g: use of an anxiolytic for discomfort: No regular training for safe and appropriate use of anxiolytics and analgesics €.g understanding their action and possible adverse effects or consideration of appropriate age related dosing Lack of an action plan for patients who do not tolerate the procedure. Lack of an action plan as to who to call for assistance in circumstances when a patients airway is lost or there is difficulty in placing a pacemaker wire Lack of understanding as to what observations are taken and are required during the procedure
e.g: belief that the pulse oximeter measures respiratory rate

Responses

1 respondent

Frimley Health NHS Trust NHS / Health Body

14 Oct 2016 PDF

Action Taken

Frimley Health NHS Trust relaunched the Trust Safe Sedation Committee and is reviewing and revising the Trustwide Guideline for Intravenous Conscious Sedation of Adults. (AI summary)

View full response

Dear Dr Henderson RE: Mr Peter KEEP (Deceased) Thank Vou for your letter dated 14th October 2016 and the attached Regulation 28 Prevention of Future Deaths Report relating to the above named_ We have reviewed the concerns raised following the Inquest into Mr Keep's death and have outlined below what actions have been taken in an effort to improve the pathway for patients requiring sedation as part of procedure. Contrary to the evidence heard at the Inquest, the Cardiology Department does have guideline for intravenous conscious sedation which was in place at the time of Mr Keep'$ procedure and which addresses many of the concerns raised through the Inquest including titration of drug doses, monitoring expected to be used, frequency of observations and training (copy enclosed): In the case of an emergency, as in any other interventional procedure, if the procedure proved to be difficult, help would be expected to be sought from other consultants_ In the event of not achieving adequate sedation to allow a procedure to continue, the procedure should either be cancelled and re- booked with an alternative plan in place or help sought from an anaesthetist and appropriate resources in order to Increase sedation whilst maintaining safety: Emergencies due to over-sedation or cardio- respiratory compromise should be escalated via Trust's normal route of cal '2222 to activate the emergency team: The Trust has also used your letter and Regulation 28 as an opportunity to relaunch the Trust Safe Sedation Committee which will be chaired by Deputy Medical Director and Chief of Service for Anaesthetics. The Committee are currently reviewing and revising the Trustwide Guideline for Intravenous Conscious Sedation of Adults addressing intravenous sedation in all clinical settings standardising the processes followed: The policy is in draft and going through the Trust'$ internal ratification processes together with the draft terms of reference for the Sedation Group (drafts of both attached): lling

The Cardiology team have discussed Mr Keep's case through their internal Morbidity & Mortallty processes to share the learning from this case and to ensure there is awareness of the expectations in terms of conscious sedation within the Cardiac Catheter Laboratory: Trust is committed to patient safety and takes cases such as this very seriously and hope this is demonstrated in our response to the concerns raised, However; if | can be of further assistance, please do not hesitate in contacting me.

Report sections

Investigation and inquest

On 18th August 2015 commenced an investigation into the death of Peter John Keep; 82 years of age. The investigation concluded at the end of the inquest on &n June 2016. The medical cause of death given was; 1a. Pulmonary Oedema 1b. Perforation of the right ventricle Ic. Insertion of pacemaker for heart block My conclusion was: Died from a recognised complication of a necessary procedure

Circumstances of the death

Mr was a generally fit and well 82 year old man who was admitted into Frimley Park Hospital on 1st August 2015 following a fall at home: During his admission he was incidentally found to have Mobitz type heart block and was recommended to have pacemaker insertion. He consented and this was undertaken on the 4th August 2015. Prior to the procedure he was very anxious and heard evidence he had a needle phobia. He was given 2.Smg 'diazemuls' (diazepam) intravenously as he was still anxious was given a further 2.5 mg 'diazemuls' some ten minutes or so later: He was then given 2.5 mg diamorphine intravenously During the initial part of the procedure heard evidence that he was relatively settled: However, the pacemaker insertion was proving difficult and required multiple attempts without success Mr Keep became uncomfortable and began waving his arms around during the time the pacemaker wires Were being inserted. heard evidence that the movement more likely than not have increased the risk of ventricular perforation. He was given a further dose of 2.5 mg diazemuls. Shortly thereafter he 'lost' his airway and required a nasopharyngeal airway and high flow oxygen mask for an unspecified period of time. No consideration was given to abandoning the procedure or to ask for assistance The pacemaker insertion continued and shortly thereafter Mr Keep had a precipitous fall in his blood pressure He was found to have developed cardiac tamponade as a consequence of a perforation of the right ventricle from the attempted insertion of a pacemaker wire_ This was treated with a pericardial drain which drained 500mls of blood. Mr Keeps blood pressure improved and a decision was made to continue with the pacemaker insertion with another cardiologist; Shortly after completion; Mr Keep suffered a pulseless electrical activity cardiac arrest and despite full resuscitation died later that night on the Intensive Care Unit in Frimley Park Hospital Keep and would

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation: Frimley Park Hospital NHS Trust has the power to take such action:

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Report details

Reference: 2016-0362
Date of report: 14 October 2016
Coroner: Karen Henderson
Coroner area: Surrey

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Apr 2017 (estimated).

Sent to

Frimley Park Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.