Stanley Babbs
PFD Report
All Responded
Ref: 2020-0225
All 1 response received
· Deadline: 30 Dec 2020
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
30 Dec 2020
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it; The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight: It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with a eGFR greater than 30}. There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30). The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast; This is SO, even though contrast is a prescription only medicine: The clinical lead stated that a radiologist will simply say "contrast" or "no contrast"_ This is the case even for those patients who have high risk of a contrast induced acute kidney injury: Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician:
Responses
Response received
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Dear Ms Persaud, BHR acknowledges the Regulation 28 and the Coroner $ concerns in relation to the use of contrast for Radiological procedures within BHR Hospitals. comprehensive Action plan has been developed by the department to improve safety across a number of issues: The following actions have been implemented to ensure safe practice with all patients undergoing a CT scan with IV contrast. Communicate new IV Contrast protocol: (As per Action 1 on the plan) Completed documents approved by Medicines Optimisation Group ("MOG") and placed on Trust intranet; communicated to staff email, WhatsApp and supported by a demonstration video on YouTube on how to authorise requests; We have communicated to all radiologists multiple platforms (radiologist huddle, governance meeting, email and REALM) on the importance of having personalised evaluation & assessment of patients having IV contrast with an EGFR of less 30 especially patients who have multiple risk factors. (As per action 2 within plan) Recording radiologist authorisation decisions on all patient request forms and uploading the form onto the RIS system. For radiologists who don't have access to the form during on call or home reporting, the decision will be recorded on the RIS system: This includes patients having an eGFR of less than 30. (As per action 2 on the plan) The radiographers & admin staff have undergone specific training so that are aware of how to upload these decisions correctly onto the patients file to ensure safe conveyance of this information. (As per action 7 on the plan) "x 0 ZrG L9 & S04 UCLPartners SmokeFREe PRIdb dkob lity Cucrng Ker SAFETY Goniatnl Chire Chair Chief Executive using they
Practice Group Direction ("PGD") approval for Radiographers/updating internal protocol to enable Radiographers to inject IV contrast on a Radiologist' s prescription, for patients with eGFR between 30 and 45 The prepared PGDs are linked to SOPs agreed within Radiology discussed at the Divisional Quality and Safety Meeting held 2/12/20. The document is currently in the final stages of approved for use across BHRUT Prescriptions for CT IV contrast for patients with eGFR < 30 to ensure these requests are appropriately authorised. (As per action 4 on Plan) Creating prescription sheet for all patients with eGFR < 30,or with any risk factor outside PGD (as per point 13 within the action plan) The prescription sheet will be Included within the PGD Creating a new Radiology request form to incorporate safeguards for patients with abnormal renal function and to confirm that the clinician has indicated the use of contrast and if a discussion has taken place with the patient about the use of contrast: Form created and will be in use by 31/12/20. (As per action 6 on plan) Scans on direct access pathway from ED which need contrast e.g: CT Angiogram for stroke will require a prescription for contrast in the patients notes. (As per action 9 on plan) Agreement that the ED clinician will sign prescription for IV contrast to cover the radiographer in patient'$ notes and scanned on to the RIS system_ This is an interim measure which will be reviewed post PGD sign off Contrast Dose: now specified as Iml/Kg with maximum of 1OOml (medical scales have been ordered for all scanners and should be in place soon): (As per action 12 on plan) To accompany this correspondence we have attached: The full Action Plan that the Trust has developed for the Radiology department to improve safety both immediately and in the long term New Radiology request form New prescription form- Patient Specific Authorisation (PSA) Document This plan has been clinically led, the Radiology Clinical Leads developing the actions with input from their Medical and AHP colleagues There has also been discussion at the Clinical reference group chaired by the Medical Director within the Trust_
Practice Group Direction ("PGD") approval for Radiographers/updating internal protocol to enable Radiographers to inject IV contrast on a Radiologist' s prescription, for patients with eGFR between 30 and 45 The prepared PGDs are linked to SOPs agreed within Radiology discussed at the Divisional Quality and Safety Meeting held 2/12/20. The document is currently in the final stages of approved for use across BHRUT Prescriptions for CT IV contrast for patients with eGFR < 30 to ensure these requests are appropriately authorised. (As per action 4 on Plan) Creating prescription sheet for all patients with eGFR < 30,or with any risk factor outside PGD (as per point 13 within the action plan) The prescription sheet will be Included within the PGD Creating a new Radiology request form to incorporate safeguards for patients with abnormal renal function and to confirm that the clinician has indicated the use of contrast and if a discussion has taken place with the patient about the use of contrast: Form created and will be in use by 31/12/20. (As per action 6 on plan) Scans on direct access pathway from ED which need contrast e.g: CT Angiogram for stroke will require a prescription for contrast in the patients notes. (As per action 9 on plan) Agreement that the ED clinician will sign prescription for IV contrast to cover the radiographer in patient'$ notes and scanned on to the RIS system_ This is an interim measure which will be reviewed post PGD sign off Contrast Dose: now specified as Iml/Kg with maximum of 1OOml (medical scales have been ordered for all scanners and should be in place soon): (As per action 12 on plan) To accompany this correspondence we have attached: The full Action Plan that the Trust has developed for the Radiology department to improve safety both immediately and in the long term New Radiology request form New prescription form- Patient Specific Authorisation (PSA) Document This plan has been clinically led, the Radiology Clinical Leads developing the actions with input from their Medical and AHP colleagues There has also been discussion at the Clinical reference group chaired by the Medical Director within the Trust_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action
Report Sections
Investigation and Inquest
On the 25th April 2016 commenced an investigation into the death of Stanley Alfred Babbs. The investigation concluded at the end of the Inquest on the 30th October 2020 The conclusion of the Inquest was a narrative conclusion: Mr Stanley Babbs died as @ result of the administration of IV contrast for a CT scan An individualised, personal evaluation and assessment was not carried out before the administration of contrast: A robust risk/benefit analysis had not been carried out prior to the administration of contrast. Mr Babbs had not been informed of the risks of administration of contrast: Communication between the referring clinician and the radiology team was deficient Had a personalised assessment; risk/benefit analysis and robust communication been carried out, on the balance of probabilities, the CT scan with contrast would not have been performed and his death at that time would have been avoided.
Circumstances of the Death
Mr Stanley Babbs was 91 years old. He had a past medical history of chronic kidney disease (stage 4), diabetes and heart failure: He had been generally well in 2015 but was noted on blood tests to have a low haemoglobin. His haemoglobin was within the target range for a patient with chronic kidney disease: Mr Babbs was referred to a gastroenterologist by his general practitioner The gastroenterologist considered that a CT scan would be required to exclude a possible malignancy. Other than the chronically low haemoglobin, there were no other clinical indicators of malignancy.The CT scan was requested and a radiologist agreed that a contrast CT scan could take place, with appropriate hydration being administered: On the 21st January 2016 a contrast CT scan took place: Following this Mr Babbs became unwell and blood tests taken on the 25th January 2016 showed a raised creatinine: He was diagnosed with a contrast induced acute kidney injury and admitted to hospital. During hospitalisation he required a catheter. Sadly, he succumbed to sepsis from a urinary tract infection and passed away in hospital on the February 2016_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.