Sultana Choudhury
PFD Report
1 of 2 responses identified
Ref: 2023-0321
All 1 listed response identified
· Deadline: 2 Nov 2023
Coroner's Concerns (AI summary)
Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, leading to preventable deterioration.
View full coroner's concerns
1. The trust's failure to diagnose an obvious ongoing renal haemorrhage in a patient with; a recent history of renal biopsy, worsening clinical observations in keeping with hypovolaemia and a plummeting haemoglobin count.
2. The clinical decision to administer VTE prophylaxis in the form of low molecular weight heparin on admission to a patient with a patent bleed, evidenced by haematuria.
3. The failure to adequately monitor Mrs Choudhury during her 3-day admission that allowed her to deteriorate into a preventable peri-arrest state.
2. The clinical decision to administer VTE prophylaxis in the form of low molecular weight heparin on admission to a patient with a patent bleed, evidenced by haematuria.
3. The failure to adequately monitor Mrs Choudhury during her 3-day admission that allowed her to deteriorate into a preventable peri-arrest state.
Responses
Action Taken
The Trust produced a Comprehensive Investigation Report and developed a robust action plan to share learning across the Trust regarding themes relating to continuity, and always ensuring effective communication during handover. (AI summary)
The Trust produced a Comprehensive Investigation Report and developed a robust action plan to share learning across the Trust regarding themes relating to continuity, and always ensuring effective communication during handover. (AI summary)
View full response
Dear Mr Irvine,
Thank you for your letter of 7 September 2023 about the death of Sultana Choudhury. I am replying as Minister with responsibility for secondary care.
Firstly, I would like to say how saddened I was to read of the circumstances of Sultana Choudhury’s death and I offer my sincere condolences to the family and loved ones. The circumstances your report describes are concerning and warrants a robust approach to prevent serious incidents of this nature in the future. I apologise for the lengthy delay in issuing a response and I am grateful to you for bringing these matters to my attention.
The key matters of concern identified in the report are, inadequate monitoring during Mrs Choudhury’s admission; failure to subsequently diagnose a deteriorating situation, and the clinical decision to administer Venous Thromboembolism (VTE) prophylaxis.
In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC). As I understand, the series of events following enquiries with NHS England, the Trust produced a Comprehensive Investigation Report in June 2023 to identify the cause of Mrs Choudhury’s death and developed a robust action plan to share learning across the Trust. I am aware that CQC asked the Trust to provide a response outlining the mitigating actions taken to address the key matters of concern identified by the Coroner in the report.
Following this, CQC continue to monitor their progress through ongoing engagement and assessment with the Trust. I am informed that Barts Health NHS Trust has taken steps to address the concerns identified by HM Coroner, particularly the themes relating to continuity of care, monitoring, escalation and assessment of interventions, diagnostic overshadowing, and always ensuring effective communication during handover - particularly during out of hours. This includes improvement work relating
to the deteriorating patient that they have prioritised as part of their Patient Safety Incident Response Plan.
More broadly, CQC observe they are still seeing themes concerning failure to recognise or act on signs that a patient is deteriorating occurring across incidents that NHS Trusts report on. They acknowledge, and I agree that embedding and sustaining improvement requires ongoing commitment and auditing activities.
Over the last decade, we have relentlessly pursued higher patient safety standards across the NHS. Together with system partners, we will keep supporting the NHS to achieve continuous improvement in leadership and safety. This includes implementing key programmes from the first NHS Patient Safety Strategy to help create a positive safety culture and a widespread focus on reducing avoidable patient harm. Several national programmes have been rolled out under the first NHS Patient Safety Strategy, including:
• the Learn from Patient Safety Events (LFPSE) Service to help providers learn from the 2 million patient safety events (the majority of which cause low harm) they record each year. and
• the Patient Safety Incident Response Framework (PSIRF) which represents a significant shift - and is a contractual requirement from April 2024 - in how providers respond and learn from patient safety incidents. We are clear that hospital leaders must embed a safety culture across their organisations. This includes by ensuring key patient safety messages permeate down to staff at the workplace. I hope this response is helpful and signifies that we are not complacent and continue to look into ways to improve patient safety and culture. Thank you for bringing these concerns to my attention.
Kind regards,
THE RT HON ANDREW STEPHENSON CBE MP MINISTER OF STATE
Thank you for your letter of 7 September 2023 about the death of Sultana Choudhury. I am replying as Minister with responsibility for secondary care.
Firstly, I would like to say how saddened I was to read of the circumstances of Sultana Choudhury’s death and I offer my sincere condolences to the family and loved ones. The circumstances your report describes are concerning and warrants a robust approach to prevent serious incidents of this nature in the future. I apologise for the lengthy delay in issuing a response and I am grateful to you for bringing these matters to my attention.
The key matters of concern identified in the report are, inadequate monitoring during Mrs Choudhury’s admission; failure to subsequently diagnose a deteriorating situation, and the clinical decision to administer Venous Thromboembolism (VTE) prophylaxis.
In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC). As I understand, the series of events following enquiries with NHS England, the Trust produced a Comprehensive Investigation Report in June 2023 to identify the cause of Mrs Choudhury’s death and developed a robust action plan to share learning across the Trust. I am aware that CQC asked the Trust to provide a response outlining the mitigating actions taken to address the key matters of concern identified by the Coroner in the report.
Following this, CQC continue to monitor their progress through ongoing engagement and assessment with the Trust. I am informed that Barts Health NHS Trust has taken steps to address the concerns identified by HM Coroner, particularly the themes relating to continuity of care, monitoring, escalation and assessment of interventions, diagnostic overshadowing, and always ensuring effective communication during handover - particularly during out of hours. This includes improvement work relating
to the deteriorating patient that they have prioritised as part of their Patient Safety Incident Response Plan.
More broadly, CQC observe they are still seeing themes concerning failure to recognise or act on signs that a patient is deteriorating occurring across incidents that NHS Trusts report on. They acknowledge, and I agree that embedding and sustaining improvement requires ongoing commitment and auditing activities.
Over the last decade, we have relentlessly pursued higher patient safety standards across the NHS. Together with system partners, we will keep supporting the NHS to achieve continuous improvement in leadership and safety. This includes implementing key programmes from the first NHS Patient Safety Strategy to help create a positive safety culture and a widespread focus on reducing avoidable patient harm. Several national programmes have been rolled out under the first NHS Patient Safety Strategy, including:
• the Learn from Patient Safety Events (LFPSE) Service to help providers learn from the 2 million patient safety events (the majority of which cause low harm) they record each year. and
• the Patient Safety Incident Response Framework (PSIRF) which represents a significant shift - and is a contractual requirement from April 2024 - in how providers respond and learn from patient safety incidents. We are clear that hospital leaders must embed a safety culture across their organisations. This includes by ensuring key patient safety messages permeate down to staff at the workplace. I hope this response is helpful and signifies that we are not complacent and continue to look into ways to improve patient safety and culture. Thank you for bringing these concerns to my attention.
Kind regards,
THE RT HON ANDREW STEPHENSON CBE MP MINISTER OF STATE
Sent To
- Barts Health NHS Foundation Trust
- Department of Health and Social Care
Responses Identified
Responses identified
1 of 2
56-Day Deadline
2 Nov 2023
All listed responses identified
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
On 19th December 2022 this Court commenced an investigation into the death of Sultana Razia Choudhury aged 60 years. The investigation concluded at the end of the inquest on 24th August 2023. The court returned a short form conclusion of accident contributed to by neglect. Mrs Choudhury's medical cause of death was determined as;
1.a. Multi-organ Failure
1.b. Hypovolaemia
1.c. Renal Haemorrhage secondary to Renal Biopsy (7th December 2022) 5
1.a. Multi-organ Failure
1.b. Hypovolaemia
1.c. Renal Haemorrhage secondary to Renal Biopsy (7th December 2022) 5
Circumstances of the Death
Sultana Choudhury was diagnosed with Diabetes and chronic kidney disease, she agreed to take part in a research project related to these conditions. On 7th December 2022 she consented to undergo a renal biopsy to harvest sample material in furtherance of the research programme. The procedure was completed after two attempts to take tissue. A week later Mrs Choudhury was admitted into hospital with abdominal pain, haematuria, rapidly worsening acute kidney injury and a positive for gram negative rods in blood cultures. Following diagnostic testing and imaging, Mrs Choudhury was admitted for treatment of a queried diagnosis of pyelonephritis and was administered enoxaparin for VTE risk. Mrs Choudhury was not adequately monitored whilst an inpatient. She died following a cardiac arrest in hospital on 17th December 2022. The cardiac arrest was caused by hypovolaemia which, in turn was caused by a undiagnosed renal haemorrhage the result of the renal biopsy 7 days earlier. The haemorrhage was exacerbated by contraindicated VTE prophylaxis. CORONER'S CONCERNS During the course of 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. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.
1. The trust's failure to diagnose an obvious ongoing renal haemorrhage in a patient with; a recent history of renal biopsy, worsening clinical observations in keeping with hypovolaemia and a plummeting haemoglobin count.
2. The clinical decision to administer VTE prophylaxis in the form of low molecular weight heparin on admission to a patient with a patent bleed, evidenced by haematuria.
3. The failure to adequately monitor Mrs Choudhury during her 3-day admission that allowed her to deteriorate into a preventable peri-arrest state. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd November 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mrs Choudhury I have also sent it to the local Director of Public Health who may find it useful or of interest. 8
1. The trust's failure to diagnose an obvious ongoing renal haemorrhage in a patient with; a recent history of renal biopsy, worsening clinical observations in keeping with hypovolaemia and a plummeting haemoglobin count.
2. The clinical decision to administer VTE prophylaxis in the form of low molecular weight heparin on admission to a patient with a patent bleed, evidenced by haematuria.
3. The failure to adequately monitor Mrs Choudhury during her 3-day admission that allowed her to deteriorate into a preventable peri-arrest state. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd November 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mrs Choudhury I have also sent it to the local Director of Public Health who may find it useful or of interest. 8
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.