Source · Prevention of Future Deaths

Khazna Khalaf

Ref: 2016-0489 Date: 18 Jul 2016 Coroner: Martin Fleming Area: West Yorkshire (West) Responses identified: 0 / 1 View PDF

Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a clear clinical protocol for initial intervention decisions and monitoring.

Date 18 Jul 2016
56-day deadline 12 Sep 2016 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a clear clinical protocol for initial intervention decisions and monitoring.
View full coroner's concerns
During the course of the inquest Inoted the full contents of the report provided byL who could not attend to give oral evidence, and it was his view that upon Jane's initial arrival at the hospital she did not present with sufficient clinical signs to justify a blood sample to determine serum sodium levels, and that there was no evidence to suggest that an early blood sample would have led to a much longer survival. This was at variance t0 the oral evidence heard an independent expert in Anaesthesia and Intensive Care Medicine, and I accepted his view thathad an early blood sample been taken prior to her collapse, it would have identified her low sodium levels such that she would have received effective treatment that would on the balance of probabilities have prevented her death: The MATTER OF CONCERN is as follows: The effectiveness of local protocols and the sufficiency of existing hospital guidelines alerting clinicians to the risks of ecstasy toxicity, the symptoms and signs it might present. To consider the appropriateness of a clinical protocol which RT3589 taking from provides structure to the initial decision to intervene Or simply monitor; and guidance on what that monitoring should consist of (and when to be concerned and reassess the initial decision)

Report sections

Investigation and inquest
On 3 December 2014
Circumstances of the death
Khazna Jane Sara Khalaf, a UK citizen was studying at Koln University as part of a student exchange On the evening of 11 November 2014 she attended at the Odonien Nightclub during the carnival celebrations The circumstances as to how she came to ingest ecstasy remain unclear; but after becoming unwell an ambulance was called at approximately 4.50am 12 November 2014 and when taken to St Marien Hospital in Cologne she was first examined at 5.03am, when records say she admitted to pill of ecstasy. Subsequently she was monitored hourly until 9.20am when she collapsed unresponsive: At 10.30am she was transferred to Merkheim Hospital, where CT head scans revealed that she had suffered cerebral oedema such that it brought about hypoxic ischaemic encephalopathy as a result of ecstasy toxicity. Thereafter she very sadly succumbed and died on 20 November 2014.

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Report details

Reference
2016-0489
Date of report
18 July 2016
Coroner
Martin Fleming
Coroner area
West Yorkshire (West)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Sep 2016 (estimated).

Sent to

St Marien Hospital Trust

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