Nisren Abdul-Karim
PFD Report
All Responded
Ref: 2024-0491
All 1 response received
· Deadline: 6 Nov 2024
Response Status
Responses
1 of 1
56-Day Deadline
6 Nov 2024
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 evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass. This meant accessing the notes required recognising that patient pass needed to be accessed. In addition the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology. As a consequence delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all contact with neurology is via telephone or patient pass as there is no face to face neurology service.
Responses
NHS Greater Manchester plans to ensure all neurology advice is provided via the Patient Pass system, update Patient Pass to include a mandatory telephone number field, and update communication guides. Tertiary services will also be required to contact referrers by telephone for time-critical actions and ensure users are aware of the system.
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Dear Ms. Mutch
Re: Regulation 28 Report to Prevent Future Deaths regarding Mrs. Nisren Abdul-Karim
Thank you for your Regulation 28 Report dated 11 September 2024 regarding the sad death of Mrs. Nisren Abdul-Karim. On behalf of NHS Greater Manchester (NHS GM), We would like to begin by offering our sincere condolences to Mrs. Karim’s family for their loss.
Thank you for highlighting your concerns during the inquest which concluded on 19 August 2024. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services.
During the inquest you identified the following cause for concern: -
The evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However, the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass. This meant accessing the notes required recognising that patient pass needed to be accessed. In addition, the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology. As a consequence, delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all Private & Confidential
Ms Alison Mutch OBE Senior Coroner for Greater Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG
4th Floor, Piccadilly Place, Manchester M1 3BN Tel:
contact with neurology is via telephone or patient pass as there is no face-to-face neurology service.
NHS GM have communicated with both provider Trusts, namely the Northern Care Alliance (NCA) and the Manchester University NHS Foundation Trust (MFT) to formulate this response. I hope the below offers assurances to both you and Nisren Abduls-Karim family that NHS GM continues to take these concerns seriously and has put in a number of steps and actions since the tragic death of Nisren Abdul- Karim.
We have identified that at that time there was no visiting neurologist covering the Trafford site. The NCA have identified this as a gap in their provision and have since recruited a neurologist who will cover the Trafford site. This role will include weekly input from neurology in terms of seeing referrals at the Trafford site.
The NCA convened a working group to improve its understanding of Patient Pass and improve the system itself to reduce the likelihood of recurrence of such an incident. In addition, the NCA have prepared a communication guide, which outlines the purpose of Patient Pass and clarifies the responsibilities of referrers and receivers. This document is due to be finalised by the end of November and will be circulated across Greater Manchester hospitals via their Medical Directors, including MFT and the Trafford site. The NCA have provided reassurance that the system will be audited regularly to ensure adherence to the referral guidelines, with feedback being issued to the referring Trust as required.
The neurology team provide ward reviews to all GM hospital sites. This is with the exception of Rochdale. As Rochdale is not an acute site, there has never been the demand for neurology inpatient reviews. Any site can always access Neurology opinion via the on-call service 24/7, and advice will be provided. Requests for ward reviews come through Patient Pass. There is currently variation in process in terms of on-going documentation after that initial request via the system. In some cases, on-going clinical advice is continued on Patient Pass (akin to how this works for on-going neurosurgical or spinal advice through the same system). This requires local hospital-based clinicians to access Patient Pass to see the documentation. In other cases, on-going clinical advice is written in the local hospital site’s notes, on whatever system exists on that site for this. The NCA propose that all neurology advice is provided via the Patient Pass system, in line with other tertiary services of neurosurgery and spinal surgery. The NCA believe that if this was in place it would prevent a recurrence of this issue.
There are plans in place to update the Patient Pass system, which will include a telephone number as a mandatory field. Any non-urgent advice will continue to be provided via the Patient Pass system, and the communication guide will also advise the referrer that Patient Pass should be accessed regularly for on- going communication with the tertiary service. The tertiary services are also required to attempt to contact the referring service via telephone when there is time critical action required by the referrer, supplemented by appropriate documentation in Patient Pass. In addition to this, there are expectations on referrers and the tertiary service at an organisational level to ensure that potential users of Patient Pass are aware of how to use the system.
I hope the above offers you reassurance of the ongoing commitment to managing patient safety risks and to continually improve the care and services we provide. Please do not hesitate to contact me if you require any further information in relation to our response.
Best wishes
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
Re: Regulation 28 Report to Prevent Future Deaths regarding Mrs. Nisren Abdul-Karim
Thank you for your Regulation 28 Report dated 11 September 2024 regarding the sad death of Mrs. Nisren Abdul-Karim. On behalf of NHS Greater Manchester (NHS GM), We would like to begin by offering our sincere condolences to Mrs. Karim’s family for their loss.
Thank you for highlighting your concerns during the inquest which concluded on 19 August 2024. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services.
During the inquest you identified the following cause for concern: -
The evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However, the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass. This meant accessing the notes required recognising that patient pass needed to be accessed. In addition, the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology. As a consequence, delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all Private & Confidential
Ms Alison Mutch OBE Senior Coroner for Greater Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG
4th Floor, Piccadilly Place, Manchester M1 3BN Tel:
contact with neurology is via telephone or patient pass as there is no face-to-face neurology service.
NHS GM have communicated with both provider Trusts, namely the Northern Care Alliance (NCA) and the Manchester University NHS Foundation Trust (MFT) to formulate this response. I hope the below offers assurances to both you and Nisren Abduls-Karim family that NHS GM continues to take these concerns seriously and has put in a number of steps and actions since the tragic death of Nisren Abdul- Karim.
We have identified that at that time there was no visiting neurologist covering the Trafford site. The NCA have identified this as a gap in their provision and have since recruited a neurologist who will cover the Trafford site. This role will include weekly input from neurology in terms of seeing referrals at the Trafford site.
The NCA convened a working group to improve its understanding of Patient Pass and improve the system itself to reduce the likelihood of recurrence of such an incident. In addition, the NCA have prepared a communication guide, which outlines the purpose of Patient Pass and clarifies the responsibilities of referrers and receivers. This document is due to be finalised by the end of November and will be circulated across Greater Manchester hospitals via their Medical Directors, including MFT and the Trafford site. The NCA have provided reassurance that the system will be audited regularly to ensure adherence to the referral guidelines, with feedback being issued to the referring Trust as required.
The neurology team provide ward reviews to all GM hospital sites. This is with the exception of Rochdale. As Rochdale is not an acute site, there has never been the demand for neurology inpatient reviews. Any site can always access Neurology opinion via the on-call service 24/7, and advice will be provided. Requests for ward reviews come through Patient Pass. There is currently variation in process in terms of on-going documentation after that initial request via the system. In some cases, on-going clinical advice is continued on Patient Pass (akin to how this works for on-going neurosurgical or spinal advice through the same system). This requires local hospital-based clinicians to access Patient Pass to see the documentation. In other cases, on-going clinical advice is written in the local hospital site’s notes, on whatever system exists on that site for this. The NCA propose that all neurology advice is provided via the Patient Pass system, in line with other tertiary services of neurosurgery and spinal surgery. The NCA believe that if this was in place it would prevent a recurrence of this issue.
There are plans in place to update the Patient Pass system, which will include a telephone number as a mandatory field. Any non-urgent advice will continue to be provided via the Patient Pass system, and the communication guide will also advise the referrer that Patient Pass should be accessed regularly for on- going communication with the tertiary service. The tertiary services are also required to attempt to contact the referring service via telephone when there is time critical action required by the referrer, supplemented by appropriate documentation in Patient Pass. In addition to this, there are expectations on referrers and the tertiary service at an organisational level to ensure that potential users of Patient Pass are aware of how to use the system.
I hope the above offers you reassurance of the ongoing commitment to managing patient safety risks and to continually improve the care and services we provide. Please do not hesitate to contact me if you require any further information in relation to our response.
Best wishes
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
Report Sections
Investigation and Inquest
On 5th August 2024 I commenced an investigation into the death of Nisren ABDUL-KARIM. The investigation concluded on the 19th August 2024 and the conclusion was one of Narrative: Died from natural causes contributed to by the complications of an accidental fall sustained whilst unobserved as an inpatient. The medical cause of death was 1a) Hospital acquired pneumonia 1b) Frailty 1c) End stage neurodegenerative condition II) Fall (1st Nov) requiring surgery for hip fracture (2nd Nov), Behcet's disease.
Circumstances of the Death
Nisren Abdul-Karim had a number of underlying health conditions including Behcet's disease. In Autumn 2023 she began to hallucinate. She was admitted again to Wythenshawe Hospital on 21st October 2023. She was a high falls risk. Whilst an inpatient and unobserved she had a fall. She should not have been unobserved. She was operated on for a fractured hip sustained in the fall. She was transferred to Trafford General Hospital for rehabilitation on 10th November. The transfer meant that access to neurology was more difficult because the service provided by neurologists was not available at Trafford General Hospital. She continued to deteriorate at Trafford General Hospital. Further advice was sought via patient pass from the neurology team at Salford Royal Hospital. Review of the scans previously undertaken concluded that she had irreversible neurodegenerative disease. She continued to deteriorate and died at Trafford General Hospital on 5th January 2024.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.