Karmchand Gulzar
PFD Report
All Responded
Ref: 2023-0550
All 1 response received
· Deadline: 23 Feb 2024
Coroner's Concerns (AI summary)
Failures in following surgical referral pathways, performing necessary CT scans, and recognizing patient deterioration due to communication issues and disregarded family concerns, despite previous warnings.
View full coroner's concerns
(1) Karmchand was referred to the surgical nursing team instead of the surgical registrar or surgical on-call team, as required by the Emergency Department to surgical registrar referral pathway from a previous SI where it had been identified as an issue. This was not followed in this case, leading to a delay in surgery and increased risk of death. I am concerned that the surgical registrar referral pathway is not being utilised despite previous incidents in which its use was highlighted as necessary.
(2) No CT scan was undertaken as required by the acute abdominal pathway and guidance as part of the initial assessment. I was concerned by evidence that a CT scan would not be undertaken urgently as part of an acute abdominal presentation and that the necessity for a scan may not be known by junior (or some consultant) doctors.
(3) The deterioration in Karmchand’s condition was not recognised due to difficulties in communication of pain due to his mental health condition. Concerns raised by his carers and family who knew him best and his presentation were not given adequate weight. A previous SI was reported to have raised this issue, but no action point or plan was provided in the current report to set out how staff could improve the assessment of patients with communication difficulties, by using observations and relying on people who better knew their demeanour and presentation.
(2) No CT scan was undertaken as required by the acute abdominal pathway and guidance as part of the initial assessment. I was concerned by evidence that a CT scan would not be undertaken urgently as part of an acute abdominal presentation and that the necessity for a scan may not be known by junior (or some consultant) doctors.
(3) The deterioration in Karmchand’s condition was not recognised due to difficulties in communication of pain due to his mental health condition. Concerns raised by his carers and family who knew him best and his presentation were not given adequate weight. A previous SI was reported to have raised this issue, but no action point or plan was provided in the current report to set out how staff could improve the assessment of patients with communication difficulties, by using observations and relying on people who better knew their demeanour and presentation.
Responses
Action Taken
Sandwell and West Birmingham NHS Trust updated and re-issued their 'Management of Acute Abdomen' guideline in June 2023 with a flowchart and emphasis on early CT scanning. They are also trialling a 'Carers Passport' to improve carer involvement in patient care in April 2024 and have identified training and education in patient experience and communication as Trust priorities. (AI summary)
Sandwell and West Birmingham NHS Trust updated and re-issued their 'Management of Acute Abdomen' guideline in June 2023 with a flowchart and emphasis on early CT scanning. They are also trialling a 'Carers Passport' to improve carer involvement in patient care in April 2024 and have identified training and education in patient experience and communication as Trust priorities. (AI summary)
View full response
Dear Mr Pemberton, Re: Mr Karmchand Gulzar (deceased)
Inquest: Black Country Coroner’s Court – 13 December 2023 Thank you for your Prevention of Future Deaths letter of the 29 December 2023 raising the concerns you have regarding the care pathway for acute abdominal conditions at Sandwell and West Birmingham NHS Trust. I would like to assure you that since this very sad case the Trust has continued to make improvements to the pathway which should now resolve the issues you have raised. The Management of Acute Abdomen guideline that was in use at the time of this incident has been updated and re-issued in June 2023. This guideline was created in consultation with the Doctors working within the Emergency Department and the Patient Safety team, to ensure the appropriate learning is incorporated into the process. The guideline aligns with the BMJ Best Practice recommendations. The updated guideline has introduced a flowchart of the pathway which was not previously included in the policy, at the time of this case. The need for early CT scanning is also emphasised throughout the guideline. There is also a process whereby all Junior Doctors discuss their concerns for patients with an acute abdomen presentation and potential surgical referral with their Consultant prior to referral, to discuss the patient needs and check the referral has been made correctly. In order to embed the new guideline, it has been sent to all applicable staff, published on our intranet site and discussed within team meetings and appropriate forums. The guidance is highlighted at induction sessions for new doctors and in appropriate teaching sessions. Staff have also been reminded to include outstanding referrals at the handover discussion. Mr Gulzar’s case has also been anonymised and discussed with the clinical teams within the Emergency and
Surgical departments to ensure our teams are aware of the learning from this case. To assess the efficacy of the activities described above, an audit of the Acute Abdomen pathway is planned in March 2024. In relation to the concerns regarding the recognition of deterioration not being recognised due to Mr Gulzar’s mental health condition and the concerns of his family/carers being ignored; there is considerable work being done by our Patient Experience team to support improvement in this area. Listening to and valuing the expertise that exists within carers and families is crucial to providing personalised care and treatment, and personalisation is a key-cornerstone of the Trust's Fundamentals of Care programme. Through this work a 'Carers Passport' with supporting patient documentation concentrating on the person, is being trialled in selected wards to understand the benefits this will reap for carers across the organisation. This trial will take place in April 2024, and we will then look to roll this out across the Trust. The supporting documentation prompts carers to describe their loved one’s individual needs and how they may express things like pain, for example. Carers have told us that they want recognition for what they bring to the care team and this project will formalise the carers' relationship with the care team as a partner in care with us. Additionally, we have identified training and education in patient experience and communication as Trust priorities. Every session delivered in the last year stresses the value of carer involvement, their specific expertise and knowledge and the benefits in experience and outcomes that these bring. The Patient Safety Incident Response Framework (PSIRF) will be commencing 1st April 2024, and one of the four main themes for learning and quality improvement for the Trust has been identified as ‘Vulnerable People’, with the first year focussing on Mental Capacity and the management of patients who may lack capacity. This will work alongside the Fundamentals of Care programme which has communication as a top priority, and the two workstreams will work together to support our vulnerable patients. I trust this information will provide you with reassurance regarding the concerns raised in your report, however if I can assist with anything further please let me know.
Inquest: Black Country Coroner’s Court – 13 December 2023 Thank you for your Prevention of Future Deaths letter of the 29 December 2023 raising the concerns you have regarding the care pathway for acute abdominal conditions at Sandwell and West Birmingham NHS Trust. I would like to assure you that since this very sad case the Trust has continued to make improvements to the pathway which should now resolve the issues you have raised. The Management of Acute Abdomen guideline that was in use at the time of this incident has been updated and re-issued in June 2023. This guideline was created in consultation with the Doctors working within the Emergency Department and the Patient Safety team, to ensure the appropriate learning is incorporated into the process. The guideline aligns with the BMJ Best Practice recommendations. The updated guideline has introduced a flowchart of the pathway which was not previously included in the policy, at the time of this case. The need for early CT scanning is also emphasised throughout the guideline. There is also a process whereby all Junior Doctors discuss their concerns for patients with an acute abdomen presentation and potential surgical referral with their Consultant prior to referral, to discuss the patient needs and check the referral has been made correctly. In order to embed the new guideline, it has been sent to all applicable staff, published on our intranet site and discussed within team meetings and appropriate forums. The guidance is highlighted at induction sessions for new doctors and in appropriate teaching sessions. Staff have also been reminded to include outstanding referrals at the handover discussion. Mr Gulzar’s case has also been anonymised and discussed with the clinical teams within the Emergency and
Surgical departments to ensure our teams are aware of the learning from this case. To assess the efficacy of the activities described above, an audit of the Acute Abdomen pathway is planned in March 2024. In relation to the concerns regarding the recognition of deterioration not being recognised due to Mr Gulzar’s mental health condition and the concerns of his family/carers being ignored; there is considerable work being done by our Patient Experience team to support improvement in this area. Listening to and valuing the expertise that exists within carers and families is crucial to providing personalised care and treatment, and personalisation is a key-cornerstone of the Trust's Fundamentals of Care programme. Through this work a 'Carers Passport' with supporting patient documentation concentrating on the person, is being trialled in selected wards to understand the benefits this will reap for carers across the organisation. This trial will take place in April 2024, and we will then look to roll this out across the Trust. The supporting documentation prompts carers to describe their loved one’s individual needs and how they may express things like pain, for example. Carers have told us that they want recognition for what they bring to the care team and this project will formalise the carers' relationship with the care team as a partner in care with us. Additionally, we have identified training and education in patient experience and communication as Trust priorities. Every session delivered in the last year stresses the value of carer involvement, their specific expertise and knowledge and the benefits in experience and outcomes that these bring. The Patient Safety Incident Response Framework (PSIRF) will be commencing 1st April 2024, and one of the four main themes for learning and quality improvement for the Trust has been identified as ‘Vulnerable People’, with the first year focussing on Mental Capacity and the management of patients who may lack capacity. This will work alongside the Fundamentals of Care programme which has communication as a top priority, and the two workstreams will work together to support our vulnerable patients. I trust this information will provide you with reassurance regarding the concerns raised in your report, however if I can assist with anything further please let me know.
Sent To
- Sandwell and West Birmingham NHS Trust
Response Status
Linked responses
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56-Day Deadline
23 Feb 2024
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 26 September 2022 an investigation was commenced into the death of Karmchand GULZAR. The investigation concluded at the end of the inquest on 13 December 2023. The findings and conclusion of the inquest were
Mr Karmchand Gulzar died at Sandwell hospital on 24 September 2022 during the course of an emergency operation to treat dilated large bowel. There had been a delay in obtaining a CT scan which showed the extent of the condition, meaning that the prospects of surviving surgery had reduced significantly by the time of the operation. Other warning signs of the significance of the surgical abdomen obstruction were not noted including a lactate level of 5 showing that Mr Gulzar was deteriorating. An immediate surgical review was not undertaken. These matters contributed more than minimally to Mr Gulzar’s death. Natural Causes contributed to by neglect. 1a Multiorgan Failure 1b Sigmoid Tumor causing Large Bowel Obstruction 1c II Schizophrenia
Mr Karmchand Gulzar died at Sandwell hospital on 24 September 2022 during the course of an emergency operation to treat dilated large bowel. There had been a delay in obtaining a CT scan which showed the extent of the condition, meaning that the prospects of surviving surgery had reduced significantly by the time of the operation. Other warning signs of the significance of the surgical abdomen obstruction were not noted including a lactate level of 5 showing that Mr Gulzar was deteriorating. An immediate surgical review was not undertaken. These matters contributed more than minimally to Mr Gulzar’s death. Natural Causes contributed to by neglect. 1a Multiorgan Failure 1b Sigmoid Tumor causing Large Bowel Obstruction 1c II Schizophrenia
Circumstances of the Death
On 23rd September 2022, Karmchand was taken from his secure care home where he was a resident under a Mental Health Act Section to Sandwell Hospital with features of abdominal distension and pain. A member of staff was with him. On arrival he was triaged at 11:01 and assessed by a physician associate at 13:34. This was reviewed by the Emergency Medicine Consultant and a diagnosis of acute intestinal obstruction was made based on the clinical assessment and x-ray of the abdomen which showed distended bowel loops. He was deemed stable and was referred to the nurse co-ordinator on the Surgical Assessment Unit (SAU) at 14:30. Evidence was provided at the inquest that the NELA (National emergency laparotomy audit) risk of death score was 2.3% at this time of referral. Crucially no CT scan was undertaken which would have provided better resolution and information on the presenting condition. Evidence was given at the inquest that this would form basic medical treatment for an acute intestinal obstruction and consideration of an abdominal emergency laparotomy. Later under examination from the trust representative, the witness recanted slightly on this stating that more junior doctors may not be minded to seek a CT scan, and commented surprisingly that requesting a scan by a consultant in the Emergency department could not be guaranteed. I received evidence in the form of the serious incident report that there were nursing shortages on that day and that the department was under considerable pressure. No surgical referral had been made. Concerns were raised that observations were not completed on time and I heard evidence from family members that their concerns about Karmchand and the pain he was suffering were not taken on board by staff. The SI report noted that there were difficulties in assessing his condition due to his mental health difficulties meaning that he could not express pain to staff as easily. His family and staff who knew him raised concerns, but adequate notice does not appear to have been taken.. At 20:30 Karmchand Deteriorated with decreasing level of consciousness and oxygen saturations and was escalated to the ED registrar and transferred to the resuscitation area where he was intubated and taken for CT scan at 22:00. The CT scan demonstrated dilated large bowel and a decision was taken for him to have urgent surgery The delay in seeking a CT scan, which did not occur until that evening meant that surgery to treat the bowel distention only occurred much later into the evening and into the early morning of 24 September 2022. By this time, the NELA risk assessment had increased from 2.3% to 52% in other words, death was more likely to occur at that point of surgery than earlier in the day. Mr Gulzar died during surgery in the early hours of 24 September 2022.
Copies Sent To
Sandwell and Brimingham NHS Trust. NHS England
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