Dear Sir,

Re: Regulation 28: Prevention of Future Deaths report – Abu Rahman (date of death: 20 November 2024)

We write to you in response to the Regulation 28: Prevention of Future Deaths report following the inquest into the death of Dr. Abu Rahman.

We would like to reiterate our sincere condolences to the family of Dr. Rahman for their loss.

The Royal Free London NHS Foundation Trust has carefully considered the matters of concern raised in the Regulation 28 Report.

We note that the two consultants involved in the case (an orthopaedic surgeon and a consultant geriatrician physician) submitted written statements but were not summoned to attend the inquest. We are grateful for the opportunity to respond to the matters you have raised.

The inquest took place on 25 and 26 March 2025 and raised two matters of concern which have been responded to in turn below:

1. Firstly, I heard evidence from the family that nursing staff were frequently unable to administer Naloxone as it had run out. They had to obtain more Naloxone from the pharmacy, which led to delays for “hours and hours” on multiple occasions.

It is recognised that the process of initiating Naloxone in Dr Rahman’s case was not in line with available best practice guidance. Bolus injections of Naloxone are recommended, to assess the response from the patient and an infusion is commenced thereafter with the dose titrated according to the amount required to achieve an initial response. It is acknowledged that awareness of this process should be shared amongst the medical team in the Acute

Medicine and Elderly Care specialities for improved management of patients in ward-based settings.

Naloxone supply on ward 8 North is a mandatory stock item which needs to be fulfilled, replenished and maintained in a timely manner. Naloxone stock is checked weekly, by the stock control pharmacist, monthly by the ward manager/ matron to ensure this supply is consistently available. Ward manager/ Matron checks are mandatory also and this is audited monthly through Tendable.

Tendable is a digital platform and mobile app designed to streamline and enhance quality audits in healthcare settings, including nursing audits.

Naloxone is kept in all ward areas as part of standard requirements for the management of opioid toxicity. It is also available in the emergency drug cupboards and further advice on obtaining supplies is available during out of hours periods through the on-call pharmacist.

Access to Naloxone during Dr Rahman’s time on 8 North was not reported to be disrupted and his medication chart records that it was administered to him between 24 minutes and 1 hour following the prescription being made, despite the significant quantity that was used. It was concluded that this was a highly unusual circumstance, in which Dr Rahman was receiving ongoing infusions, requiring an unusually large quantity of Naloxone, as a result impacting the time to administer.

Clarity on the process of accessing Naloxone, including out of hours, should stock need replenishing will be shared at daily huddles for two weeks. In addition, pharmacy will be increasing the stock level on 8 North ward to reduce the likelihood of it not being immediately available. Stock levels have been increased from 2 boxes to 3 boxes which under expected usage levels provides a sufficient supply for more than 24 hours.

2. Secondly, I heard evidence concerning a lack of awareness or appreciation concerning the risk of opioid toxicity/ accumulation in patients with kidney impairment/failure, even where the “correct” dose may have been given.

During Dr Rahman’s time on ward 8 North and following the initial Naloxone infusion there were various components which determined his clinical condition which were consistently and appropriately managed throughout his admission.

Dr Rahman attended Royal Free Hospital (RFH) Emergency Department (ED), following a road traffic accident and subsequent fall, resulting in a left intracapsular fracture of the neck of femur (NOF). On admission to Royal Free Hospital Dr Rahman underwent surgery (a left cemented hemiarthroplasty) on 8 November and was noted to be recovering well. However, in the days following, his daughter raised concerns of the administration and accumulation of opioids, as Dr Rahman had an increase in drowsiness and showed signs and symptoms of delirium.

On 14 November, Naloxone was given and although Dr Rahman showed some improvement in relation to his level of alertness this was not an immediate response that would be expected when dealing with opioid toxicity. There is evidence of regular assessments of Dr Rahman’s level of alertness including pupil size and responses and there doesn’t appear to be any correlation with the administration of the naloxone. The medical team involved in Dr Rahman’s care continued the Naloxone infusions at the wishes of his daughter.

Dr Rahman’s analgesia was prescribed in line with the new national advice issued via the MHRA regarding the use of opioids for the relief of post-operative pain. This advice was assessed through the Drugs and Therapeutics Committee and Medicines Safety Committee and enacted rapidly in advance of Dr Rahman’s admission. In addition, a new prescribing process has been developed for the EPR system to support prescribing clinicians and improve patient safety.

The Royal Free Hospital is a regional centre for renal medicine with active input to patients in outpatient and inpatient settings, including for Dr Rahman. This also extends to local guideline development which are written to account for the needs of our hospital population of patients with chronic kidney disease. Oxycodone is the strong opioid recommended for use in acute pain for patients with renal impairment within the local prescribing guideline, Acute Pain in Adults Prescribing Guide, available through Freenet (Royal free Hospital Intranet resource).

Considering Dr Rahman’s diagnosis of end stage renal failure the half-life (the time it takes for the amount of a drug’s active substance in your body to reduce by half) of oxycodone in patients increases by up to 1.7 times compared to patients with normal renal function. A review by a Consultant Nephrologist and Lead Renal Pharmacist confirmed that the final dose of Oxycodone administered at 10:04 on 11 November 2024 would have been expected to have been metabolised that afternoon. From the information gathered, following a review of the patient's medical records with input from an expert panel, it was concluded that the patient in this case was unlikely to have opioid toxicity.

Unfortunately, this does not appear to be reflected in the statements submitted and the clinical team were not invited to attend court in order so did not have the opportunity to give further clarification.

The patient subsequently developed a pneumonia, and sadly deteriorated. The hypoactive delirium appeared most likely to have contributed to acute this deterioration, in addition to his renal failure and other significant parallel co-morbidities.

The Trust is committed to learning from Dr Rahman’s tragic death and continuously improving patient safety. We will actively monitor adherence to the ongoing improvement plans and the Trust’s action plan is set out below. This will be monitored by the Acute Medicine, Emergency Department and Elderly Care (AMEDEC) Divisional Quality & Safety Board and the Clinical Performance and Patient Safety Committee.

Action Plan Safety action description

Responsibility for monitoring/ oversight

Action Deadline Evidence Relevant Recommendation -
1. Safety Huddle bitesize sessions on the process of accessing Naloxone, including out of hours, for stock replenishment for 2 weeks

Matron for Acute Medicine 13/06/2025 Email confirmation
2. Pharmacy to increase the stock level of Naloxone from 2 boxes to 3 on ward 8 North to reduce the likelihood of it not being immediately available. Ongoing audits to ensure consistent stocking. Principal Pharmacist - Clinical Governance and Medicines Safety

13/06/2025 Copy of audit
3. Update and distribute local guidelines on the management of opioid toxicity in adult patients. (Interim advice will be shared based on current national best practice guidelines.)

Principal Pharmacist - Clinical Governance and Medicines Safety

01/08/2025 Copy of guideline

We will be sending a copy of this letter to North Central London Integrated Care Board.

If you would like any further information about any part of this letter, please do not hesitate to contact us.