Source · Prevention of Future Deaths

Nicos Michael

Ref: 2014-0168 Date: 14 Apr 2014 Coroner: Rebecca Cobb Area: Kent (North-East) 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryInconsistent and incomplete documentation of the patient's allergies across multiple hospital records meant this critical information was not consistently available to staff or shared with the GP. Current medical reporting and computer systems do not adequately ensure allergy information is readily accessible for patient treatment.

Date 14 Apr 2014

56-day deadline 9 Jun 2014 est. estimated from the report date

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Inconsistent and incomplete documentation of the patient's allergies across multiple hospital records meant this critical information was not consistently available to staff or shared with the GP. Current medical reporting and computer systems do not adequately ensure allergy information is readily accessible for patient treatment.

View full coroner's concerns

the day: dizzy

(1) There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which helthey waslwere aware he was allergic This led to there conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen): (2) The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary to suggest that at a past medical attendance & reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP (3)The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital's staff when next treating that patient cannot be over-emphasised_ There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However; the evidence also showed that the medical reporting and computer systems for patient tracking do not currently allow this facility in such a way, although the relevant Trust teams are investigating how this data recording can be made more accurate_ (4) Although the Trust has indicated that electronic prescribing should now be prioritised (which it considers could potentially have flagged up the historic allergy documentation) , the RCA gave no indication that this would be compulsory for the future, or that any steps were being taken to encourage or make compulsory the checking of earlier paper records for information contained therein on allergies_

Responses

1 respondent

East Kent Hospitals University

NHS Trust

Letter dated 30 Apr 2014 PDF

AI-classified response stance Noted

AI-generated response summary

• The Trust stated there was no consistently recorded allergy to penicillin in the deceased's healthcare records. • The Trust noted the deceased did not articulate a penicillin allergy at pre-operative assessment, but did state allergies to Ibuprofen and Aspirin. • The Trust confirmed staff on ICU and Kent Ward were aware of the deceased's reported allergies.

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Dear Ms Cobb Re: Nicos Andreas MICHAEL deceased Following the conclusion of the Inquest hearing into the death of Mr Nicos Andreas MICHAEL on 01 April 2014 and your subsequent letter dated 14 April 2014 pursuant to paragraph 7 Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, write to inform you of the actions and considerations taken by East Kent Hospitals University NHS Foundation Trust_ note the concerns raised in your letter regarding the recording of a reported allergy to penicillin throughout the healthcare records pertaining to Mr Michael_ am concerned that the issues that you highlight are based solely on the findings of the Root Cause Analysis undertaken into this case and the various statements provided by the staff involved in the care and treatment of Mr Michael. There were no members of staff called to the Inquest into Mr Michael's death who may have been able to respond to your specific questions on this matter and explain the current process for recording allergies to You more clearly: will comment on your findings in the order they appear in your report: There was no consistently recorded allergy to penicillin contained in the healthcare records held by the Trust Indeed the patient himself did not articulate an allergy to penicillin at his pre-operative assessment; he did state allergies to Ibuprofen and Aspirin and red 'known allergy" wristbands were applied from the date of his admission_ The staff on ICU and on Kent Ward were all aware of Mr Michael's reported allergies There was a single reference to an allergy recorded in one volume of records embedded within the Surgical Integrated Care Pathway. The type of allergylsensitivity was not quantified in any way The allergy was not documented in prior or subsequent set of Putting paticnts first 2014 any

Report sections

Investigation and inquest

On 25ih July 2013 commenced an Investigation into the death of Nicos Andreas MICHAEL, aged 65 years_ The Investigation concluded at the end of the Inquest on 1st April 2014. The conclusion of the Inquest was a Narrative (as set out in the first paragraph of box 4 below, the clinical cause of death being 1a. Acute Anaphylaxis to intravenous penicillin_ Abdominal aortic aneurism (operated).

Circumstances of the death

Mr. Michael died on 1st November 2013 in Kent and Canterbury Hospital, Ethelbert Road, Canterbury, Kent as a result of an acute anaphylactic reaction to Augmentin that was administered intravenously to him at the hospital at around 5.15pm on 30th October 2013 in Kent Ward despite existence of an old hospital record of a reaction to Augmentin, although there was conflicting evidence as to whether Mr: Michael had on this admission given information of penicillin being one of his allergies. He had informed his dentist of that allergy, but his GP only had a record of an adverse reaction to Ibuprofen: Mr MICHAEL was admitted to the hospital on 28ih October 2013 for an elective repair of his abdominal aortic aneurism, which was carried out later that On 30h October 2013 his blood pressure was elevated, his oxygen saturations were low and he complained of feeling hot;, and nauseous although his temperature was within normal range. Ultimately, he was administered intravenous Augmentin antibiotic and almost immediately suffered a cardiac arrest which caused a significant brain injury from which recovery was not possible_ Active treatment was withdrawn; with the consent of his family, and he died on the Intensive Care Unit on 1st November 2013

Action should be taken

In my opinion, urgent action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:

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Shared signals

Report details

Reference: 2014-0168
Date of report: 14 April 2014
Coroner: Rebecca Cobb
Coroner area: Kent (North-East)

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: 9 Jun 2014 (estimated from the report date).

Sent to

East Kent Hospitals University NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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