RESPONSE TO REGULATION 28 CORONER'S REPORT TO PREVENT FUTURE DEATHS ThiS RESPONSE IS MADE ON BEHALF OF University College London Hospitals NHS Foundation Trust REGULATION 28 reporT TO PREVENT FUTURE DEATHS This response follows a report by R Brittain, Assistant Coroner for Inner North London dated 7th 2014 INVESTIGATION AND INQUEST The inquest in question relates to the death of Peter John BROOKES, who died at University College London Hospital on 27th August 2013. His inquest was commenced on 3 September 2013 and concluded on 30 April 2014 The conclusion of the_inquest was narrative CIRCUMSTANCES OF THE DEATH Mr Brookes had a background medical history which included Parkinson's disease (PD) and ischaemic heart disease He was admitted to University College Hospital (UCH) in early August 2013 for removal of a cancerous skin lesion: He was catheterised postoperatively: This resulted in some bleeding; which was thought to be resolving and the catheter was removed: The bleeding recurred, which resulted in a short readmission to UCH and warranted reinsertion of a catheter. Mr Brookes was admitted for a third time on 17 August after the catheter became blocked: During this admission there were issues regarding the sourcing and administration of Mr Brookes' PD medication, meaning that he did not receive his medication as prescribed. On 18 August Mr Brookes had a period of 'agitation' and rapid breathing, which the nursing staff felt warranted review by the ward doctors, although his symptoms did resolve after administration of relief_ This review did not occur despite repeated requests from the nursing staff _ heard evidence that weekend ward rounds routinely take most of the day to complete , which might mean that the on call team were so busy that nonemergency reviews would not occur_ In the morning of 19 August Mr Brookes suffered a respiratory arrest, which resulted in his admission to the Intensive Care Unit (ICU): Subsequent investigations demonstrated that Mr Brookes had suffered a heart attack Whilst on the ICU it was discovered that one of the PD medication boxes (Amantadine) actually contained another medication , as consequence of a dispensing error in the hospital pharmacy: There was no evidence that Mr Brookes had been administered the wrong medication_ Mr Brookes developed bronchopneumonia and continued to deteriorate, despite ongoing medical _treatment Hedied on 27 August 2013 CORONERS CONCERNS As an organisation we are mindful of our duty to consider your report and indeed have carried out a full review of the issues raised. have sought advice_from a number of areas,_including_the_head of pharacyand May pain

RESPONSE TO REGULATION 28 CORONER'S REPORT TO PREVENT FUTURE DEATHS divisional clinical director for clinical support, clinical nurse specialist for Parkinson's Disease, a consultant neurologist and clinical leads and managerial staff for the Urology specialty: The MATTERS OF CONCERN are as follows_ (1) The administration of PD medication in hospital routinely does not follow patients' usual regimens and that this, in itself, could cause physiological stress and contribute to early death: It was not possible conclude that; on the balance of probabilities, this was the case in Mr Brookes death but it was clear that this was a continuing risk; which could result in future deaths_ (2) The risks posed by the unavailability of doctors for nonemergency reviews, during weekend shifts, raises concern that future deaths could occur as a consequence_ (3) The cause of the dispensing error, that resulted in the wrong medication being in a box labelled as 'Amantadine' was not elucidated during the inquest and raises concern that future similar errors could recur; with potential for future deaths resulting: ACTION TAKENIIMESCALE (1) heard evidence that the administration of PD medication in hospital routinely does not follow patients' usual regimens and that this, in itself, could cause physiological stress and contribute to early death: It was not possible conclude that; on the balance of probabilities, this was the case in Mr Brookes death but it was clear that this was a continuing risk_which could result in future deaths The Trust recognises the importance of ensuring medications, particularly those relating to PD and other time sensitive medication are taken in accordance with the patients usual medication schedule. A approach to this in the Trust's specialist PD area is through promoting and encouraging self medication where appropriate. In order to ensure staff across the Trust are alerted to the critical importance of ensuring PD patients take their medication on time the following actions will be taken. Action Owner Complotion date An item to be included in the Quality and Safety newsletter July 2014 Link to Parkinson's Disease website July 2014 and reference to 'Get it on time' video to be included in the Q&S newsletter. Awareness to be raised via the Trust August 2014 Clinical Practice Facilitators forum. 2 put key July

RESPONSE TO REGULATION 28 CORONER"S REPORT To PrevENT FUTURE DEATHS (2) The risks posed by the unavailabilityor doctonafoutndeetecould occur as a weekend shifts, raises concern that future deaths reviews, during consequence systems in place for the Provision of urgentihedenon urgent medical The Trust has in particular there is: cover over the weekend period; For Urology which provides essential cover Urology ward Senior House Officer SHO) duties for the elective wards (T6 and T10) from 8am Spm performing and ward reviews Officer (SHO) post which provides emergency surgical A surgical Senior House Department cover primarily to Accident and Emergency ward rounds on elective A Veologv Specialty Registrar (SpR) "hGrortohes Srloard faturGays &rd warcorognds accompanied by the ward SHO TheoSeR and must be no more and is available on an on call mobile phone 24/7 Sundays from the hospital at any one time: than 1 hour away and advice as needed and An on Urology consultant who provides support _ attends the hospital when required. However, If the nursing The SHO is usually contacted via the hospital bleseer for whatever reason (which was staff are unable to make contact via the bleene advised to contact the medical staff thai situation Which arose with Mr Brookes) there to the wards on a quarterly basis Je tneia rrobile phones A siat diroctorcondaidedumbersodcinica gn anagerial (most recently circulated in June 2014 contaios contacted nursing staff are Staofin ehe Urology specialty; If the SHO canot be to senior registrar and instructed to escalate through the medica? cOeOC the ward sister or charge consultant level if necessary this would be supported by apply but with site nurseifartheverea Af weekends the sarscasatingtibasevstemheoperapons centre rather practitioner available to support nursesescalatiog this process of escalation is phan ward sister. During evenings (8.0Opm
8.OOam) unable to contact a Senior by the hospital at night team serviceh Hhaurish which is led by managed_ bleep would escalate through the night triage House Officer by based in the operations centre the night site practitioner been included in nursing staff local inductionfo The escalation process has recently escalation process and where to access ensure that all new starters clear of the and physically stored in folders on "directory which is saved on a shared server the staff the ward; in November 2013 by the introduction of The of cover was further strengthened rotation: The Urology SpR of ofthe week' on call rota rather thanea 12 houdva for both and A&E an 'SpR dedicatecentirely to on call duties and is avaiable reduced the the week is during the week (8am 8pm) : This has patients at both weekends and is the possibility of actions being missed, pumber of handovers which is where there processes across the Trust will be A further action to raises awareness 0f escalation Andethekactvon the July Qualityand_Safetynewsletter 3 post general call system. system are system would system system are system ward

RESPONSE TO REGULATION 28 CORONER"S REPORT To PREVENT FUTURE DEATHS error; that resulted in the wrong medication being put (3) The cause of the dispensing not elucidated during the inquest and raises in a box labelled as 'Amantadine' , was with potential for future deaths resulting: concern that future similar errors could recur, that medication errors relating to the prescribing, dispensing and The Trust recognises is risk facing ali NHS Trusts. In recognition of this administration of medications a key reduction programme in place: In the Trust has an ongoing and comprehensive risk number of routine processes in relation to dispensing errors in particular there were & to minimise the risk to the error: These are: place tOndependent double check in piace for dispensed medicineom of medications are stored in and dispensed from pharmacy robots The majority to minimise picking errors Where packs are not able to be stored in the robot similar looking/sounding apa Gstored in separate areas t0 try and avoid possible picking errors drugs lettering (the practice of writing part of a drug's name in upper We use Tallman sound-alike, look-alike drugs from one another in case letters to help distinguish order to avoid medication errors) assistants and complete All dispensers trained pharacy technicians or during induction to ensure that competent in the dispensing logs Aspeecikerprarcepharmacists or qualified accredited checking technicians and All checkers are have €o complete checking logs to ensure competence errors that leave the pharmacy department are Any dispensing/checking thoroughlycwviacicered are reviewed at the pharmacy clinical governance All pharmacy incidents meeting and actions plans monitored when appropriate have been implemented which further minimise the Following the error other changes risk: continuous monitoring of 'in process' dispensing errors (iLererreds A system of has been implemented. This data is reported picked up at the checking stage) areas and for all dispensing staff in the and reviewed monthly for all dispensary trust_ involved in any errors that leave the Stati (both disperserread cenklete) (eilecteve gtatemenos as to why they felt the department are required to complete lessons learnt to try and prevent a error occurred and include self-reflection on_ checking/dispensing logs to eerocorrence They are also required to complete assess competency. themes identified are shared with staff at dispensary Dispensing errors and any to avoid similar occurrences. meetings to raise awareness and share learning THIS RESPONSEHAS BEENRREPIREDEY Professor
5) DATE OF RESPONSE 2nd July 2014 prior are they are