Samsam Ateye
PFD Report
All Responded
Ref: 2024-0662
All 1 response received
· Deadline: 29 Oct 2024
Coroner's Concerns (AI summary)
The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent future deaths.
View full coroner's concerns
During the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. 1. The policy for testing for Covid-19 before cardiac surgery, specifically valve replacement surgery..
Responses
Noted
NHS England acknowledges the concerns raised and refers to existing national guidance on COVID-19 testing for elective care. They also mention internal discussions and learning from PFD reports. (AI summary)
NHS England acknowledges the concerns raised and refers to existing national guidance on COVID-19 testing for elective care. They also mention internal discussions and learning from PFD reports. (AI summary)
View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Samsam Haji Ali Ateye who died on 12 May 2023
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 3 September 2024 concerning the death of Samsam Haji Ali Ateye on 12 May 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Samsam’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Samsam’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to respond to your Report, and I apologise for any anguish this delay may have caused to Samsam’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.
Your Report raised concerns over the policy for testing for COVID-19 before cardiac surgery, specifically valve replacement surgery.
NHS England published advice on COVID-19 testing for elective care pre-admission patients in early 2022. This can be found here: NHS England » COVID-19 standard operating procedure: testing for elective care pre-admission patient
The document advises that a risk-based approach should be taken between patients and clinical teams in all cases, including where test results are positive. Individual NHS Trusts are responsible for implementing and following processes to manage COVID- 19 risks and appropriately consent patients.
This approach is reflective of guidance (second version published in February 2022 and latest version published in June 2023) by The Association of Anaesthetists, Federation of Surgical Speciality Associations, Royal College of Anaesthetists, and the Royal College of Surgeons. Both versions make clear the need for risk assessment to balance the risks of proceeding with surgery versus postponement, considering the severity of the patient’s illness/condition and the severity of their COVID-19 infection.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
22 November 2024
NHS England notes that the Royal Brompton & Harefield NHS Foundation Trust, where Samsam underwent her surgery, published a COVID-19 and heart surgery Patient Information Leaflet in May 2020. This states that where patients receive positive COVID-19 test results, transfer to Harefield Hospital cannot happen straightaway, and that an expert panel will review cases where delaying operations poses a high risk. It is difficult for NHS England to provide further comment on Samsam’s care from the information in your Report and it is not clear why the operation went ahead before the results of the second COVID-19 PCR test were known. I would therefore refer the Coroner to the Trust for further information and for their most up- to-date position on COVID-19 pre-operative testing.
I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Samsam, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 3 September 2024 concerning the death of Samsam Haji Ali Ateye on 12 May 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Samsam’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Samsam’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to respond to your Report, and I apologise for any anguish this delay may have caused to Samsam’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.
Your Report raised concerns over the policy for testing for COVID-19 before cardiac surgery, specifically valve replacement surgery.
NHS England published advice on COVID-19 testing for elective care pre-admission patients in early 2022. This can be found here: NHS England » COVID-19 standard operating procedure: testing for elective care pre-admission patient
The document advises that a risk-based approach should be taken between patients and clinical teams in all cases, including where test results are positive. Individual NHS Trusts are responsible for implementing and following processes to manage COVID- 19 risks and appropriately consent patients.
This approach is reflective of guidance (second version published in February 2022 and latest version published in June 2023) by The Association of Anaesthetists, Federation of Surgical Speciality Associations, Royal College of Anaesthetists, and the Royal College of Surgeons. Both versions make clear the need for risk assessment to balance the risks of proceeding with surgery versus postponement, considering the severity of the patient’s illness/condition and the severity of their COVID-19 infection.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
22 November 2024
NHS England notes that the Royal Brompton & Harefield NHS Foundation Trust, where Samsam underwent her surgery, published a COVID-19 and heart surgery Patient Information Leaflet in May 2020. This states that where patients receive positive COVID-19 test results, transfer to Harefield Hospital cannot happen straightaway, and that an expert panel will review cases where delaying operations poses a high risk. It is difficult for NHS England to provide further comment on Samsam’s care from the information in your Report and it is not clear why the operation went ahead before the results of the second COVID-19 PCR test were known. I would therefore refer the Coroner to the Trust for further information and for their most up- to-date position on COVID-19 pre-operative testing.
I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Samsam, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Sent To
- NHS England
Response Status
Linked responses
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56-Day Deadline
29 Oct 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
Report Sections
Investigation and Inquest
An investigation was commenced into the death of Samsam Haji Ali Ateye, aged 68. The investigation concluded on 30 August 2024. The conclusion in the inquest was: Complications following surgical procedure.
The medical cause of death was 1a Multiorgan failure 1b Following bio prosthetic aortic valve replacement surgery 1c Aortic stenosis with ventricular hypertrophy and fibrosis II Disseminated intravascular coagulopathy and thrombocytopenia with microvascular thrombotic involvement of hands and feet (managed conservatively), adult respiratory distress syndrome and acute bronchopneumonia
The medical cause of death was 1a Multiorgan failure 1b Following bio prosthetic aortic valve replacement surgery 1c Aortic stenosis with ventricular hypertrophy and fibrosis II Disseminated intravascular coagulopathy and thrombocytopenia with microvascular thrombotic involvement of hands and feet (managed conservatively), adult respiratory distress syndrome and acute bronchopneumonia
Circumstances of the Death
Samsam died on 12 May 2023 at Harefield Hospital, Uxbridge. She had been diagnosed with severe aortic stenosis which was symptomatic. A Multi-Disciplinary Team (MDT) meeting decided that she would benefit from aortic valve replacement surgery. She had an out-patient pre-operative Covid-19 Polymerase Chain Reaction (PCR) test performed on 18 April 2023, which was negative. She was admitted to hospital on the day of her surgery on 20 April 2023. On admission, she had another Covid-19 PCR test performed on her that morning, before her surgery. She had aortic valve replacement surgery that afternoon. Post-operatively, the surgeons who operated on her became aware, that evening, that the Covid-19 PCR test performed on her on the morning of surgery was positive. A subsequent three further Covid-19 tests performed in hospital after 20 April 2023 were also positive. Post-operatively, she developed episodes of atrial fibrillation, as well as sepsis which was probably bacterial and was of unknown origin. She died due to sepsis which caused Multi-Organ Failure. The inquest heard evidence that the consultant surgeon was very worried upon learning that Samsam was Covid positive as patients who are Covid positive who undergo cardiac surgery have a real risk of excessive complications and mortality. The inquest heard that policy about pre-operative testing for Covid for cardiothoracic surgery and the form of that testing was formulated at a national level by NHS England.
Copies Sent To
23. Guys and St Thomas’ NHS Foundation Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.