Source · Prevention of Future Deaths

Rafel Delezuch

Ref: 2015-0024 Date: 27 Jan 2015 Coroner: Martin Gotheridge Area: Leicester City & South Leicestershire Responses identified: 1 / 1 View PDF

Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications for rapid tranquilisation, leading to unsafe practices.

Date 27 Jan 2015

56-day deadline 24 Mar 2015

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications for rapid tranquilisation, leading to unsafe practices.

View full coroner's concerns

(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy.

(2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position

(3) When it was decided that the patient was in need of rapid tranquilisation then: a) A supply of Lorazapam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazapam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated.

(4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action by way of appropriate policies, and above all ensuring training so that all members of the clinical staff are aware of those policies. Also a review of medecines that should be maintained in ED for use when Rapid tranquilisation is necessary may help to avoid future deaths.

Responses

1 respondent

University Hospitals of Leicester NHS / Health Body

24 Mar 2015 PDF

Action Taken

All clinical staff in the Emergency Department are now aware of the Trust's Restraint Policy and the dangers of prolonged restraint in the prone position. The Chief Pharmacist has met with the Leicestershire Partnership Trust to develop a shared rapid tranquilisation guideline, expected to be in place by the end of May 2015. (AI summary)

View full response

Dear Mrs Mason Re: Rafal Delezuch write further to the Regulation 28 report sent to us on 29 January 2015 by your Assistant Coroner, Mr M Gotheridge and am now in a position to respond: Inote that the matters of concern are as follows: - Many of staff in the emergency department were unaware of and had no training in the application of the Trust's Restraint Policy. The Senior Registrar was not familiar with the dangers of prolonged restraint in the prone position. When it was decided that Mr Delezuch needed rapid tranquilisation, cllnicians a) were not aware of the avallability of alternative medication lorazapam b) the importance of quick acting drugs, did not appear to be fully appreciated. The reference In the NICE Guidelines to diazepam 'not recommended" was overlooked. You have suggested that all clinical staff be made aware of these policies also that a review of medicines that should be maintalned in our Emergency Department for use when tranqullisation Is necessary: am pleased to be able t0 report that since the Inquest, the Clinical Director for Emergency and Specialist Medicine, has met with the Head of Service for the Emergency Department and our Chief Pharmacist and will be undertaking action to strengthen and improve our processes. This case has been discussed at an Emergency Departmental meeting and has been reported to our Adverse Events University Hospitals of Lcicester NHS Trust includes Glenfield Hospital, Leicester Gencral Hospital Leicester Royal Infinary Websile: www leicesterhospitals nhs net Chairman; Mr Karamjit Singh Chief Executive: Mr John Adler Mason being and rapld and

Committee which Is chaired by a senior clinical manager and will be discussed at our next Executive Quality Board which Is chaired by myself: The Clinical Director and Head of Service for the Emergency Department between them have ensured that all clinical staff in the Emergency Department are aware of the Trust's Restralnt Pollcy and of the particular dangers of prolonged restraint in the prone position; In addition, our Chief Pharmacist has met with the Leicestershire Partnership Trust to develop a shared rapld tranquilisation guldeline; our Clinical Director will ensure that this guldeline is in place by the end of May 2015 This Guideline will also deal with appropriate consideration of the relevant NICE Guidelines_ Additionally working alongside an external organisation we are undertaking work to improve the accessibility of our Trust Policy and Guidelines generally; We expect that this work to improve the accessibility of our Policy and Guideline Library and is expected to be completed by the end of June 2015. trust that this response assures you that we take these matters seriously and if you have any further concerns please do not hesitate to contact me. Kind regards

Report sections

Investigation and inquest

On 23 August 2012 I commenced an investigation into the death of Rafal Delezuch. The investigation concluded at the end of the inquest on 23rd January 2015. The conclusion of the inquest was that Mr. Delezuch died from Amphetamine induced delirium in association with prolonged struggle.

Circumstances of the death

Early in the morning, from about 06.00 onward, the patient was seen to have been acting in a bizarre manner in the Highfields area of Leicester, including knocking on doors and exhibiting symptoms of paranoia. The police were called. The patient voluntarily got into the back seat of a police car, but then became agitated and the officer attempted (without success) to subdue him by use of his captor spray. 3 other officers eventually attended the scene and the patient was restrained and detained under S.136 M.H.A. and taken to L.R.I. in the back of a police van.

Copies sent to

) and to Weightmans (solicitors for the Police)

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Report details

Reference: 2015-0024
Date of report: 27 January 2015
Coroner: Martin Gotheridge
Coroner area: Leicester City & South Leicestershire

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: 24 Mar 2015.

Sent to

Leicester University Hospitals NHS Trust

Source links

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Data: judiciary.uk under OGL.