Shyama Rampadaruth
PFD Report
All Responded
Ref: 2021-0005
All 1 response received
· Deadline: 11 Mar 2021
Coroner's Concerns (AI summary)
A frail, elderly patient suspected of COVID-19 waited six hours in discomfort for dialysis. No attempt was made to contact family for temporary care, despite their proximity and willingness.
View full coroner's concerns
When COVID19 was suspected at her routine dialysis appointment on 13 April, precautions were taken to separate Ms Rampadaruth from other patients to reduce the risk of transmission. She was re-allocated to the evening dialysis clinic with other potentially infectious patients, so that the unit could be thoroughly cleaned overnight to make it safer for patients at the next clinic the following day.
However, this meant that Ms Rampadaruth had to wait for approximately six hours on a hard chair in a hospital waiting area. This is clearly sub optimal for the health of a frail, elderly lady with multiple co-morbidities.
The patient transfer service is likely to have been busy, but Ms Rampadaruth and her husband lived nearby. Her niece, who was very involved with her care, works locally. A quick call to a family member would have resulted in immediate arrangements being made to collect Ms Rampadaruth, bring her home to sit in comfort with familiar company and her usual food and drink, and then to return her when hospital staff were ready to begin her dialysis. Her general well being could have been so enhanced by just a small change to administrative arrangements.
However, this meant that Ms Rampadaruth had to wait for approximately six hours on a hard chair in a hospital waiting area. This is clearly sub optimal for the health of a frail, elderly lady with multiple co-morbidities.
The patient transfer service is likely to have been busy, but Ms Rampadaruth and her husband lived nearby. Her niece, who was very involved with her care, works locally. A quick call to a family member would have resulted in immediate arrangements being made to collect Ms Rampadaruth, bring her home to sit in comfort with familiar company and her usual food and drink, and then to return her when hospital staff were ready to begin her dialysis. Her general well being could have been so enhanced by just a small change to administrative arrangements.
Responses
Action Taken
Barts Health NHS Trust now swabs all dialysis patients weekly, isolates COVID-positive patients on a single site, and has access to portable dialysis machines. They have also started vaccinating dialysis patients during their sessions and are actively planning to increase dialysis capacity. (AI summary)
Barts Health NHS Trust now swabs all dialysis patients weekly, isolates COVID-positive patients on a single site, and has access to portable dialysis machines. They have also started vaccinating dialysis patients during their sessions and are actively planning to increase dialysis capacity. (AI summary)
View full response
Dear Ms Hassell,
RE: Regulation 28 Prevention of Future Deaths Report
I write in response to your Regulation 28: Report to Prevent Future Deaths, dated 11th December 2020. Your concern was related to the environment Ms Shyama Vadwatee Rampadaruth waited in on the 13th April 2020.
At the inquest you raised the concern that Ms Rampadaruth waited 6 hours on a hard chair in the hospital waiting area rather than being allowed to go home while she waited for an evening dialysis session.
This event took place during the first peak of Covid 19 in April 2020 and the steps taken that day were an emergency measure. The team recognise that the lady’s experience of waiting for her dialysis session would have been better in her own home rather than in the hospitals waiting area.
I would like to assure you that since that day a significant number of actions have taken place to improve the experience of patients attending dialysis. All dialysis patients are now swabbed weekly so Covid cases are picked up on asymptomatic patients. This has allowed us to isolate and cohort Covid positive patients in a more planned fashion than Ms Rampadaruth experienced during the first wave and we have, so far, been able to keep all our covid positive dialysis on a single site. Additionally the renal team now have access to portable dialysis machines that were not available during the first surge in March and April 2020. This has given the team more flexibility in arranging urgent isolated dialysis when needed.
Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES Telephone:
Chief Medical Officer
Private & Confidential Ms Mary Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP
The dialysis service runs at over 99% capacity and so a lack of reserve does make managing dialysis safely through the pandemic extremely challenging. They are therefore actively planning to increase capacity and are seeking the resources needed to enable this.
Finally the renal team recognise that vaccinating their vulnerable cohort of patients is likely to be the best strategy to prevent future deaths among their vulnerable cohort of patients. They have been strongly advocating for this and I am pleased to say we have started vaccinating the dialysis patients when they attend for their sessions.
Thank you for bringing your concerns to my attention. I trust that you are assured that I have taken them seriously. I am very happy to discuss or clarify any of the above points.
RE: Regulation 28 Prevention of Future Deaths Report
I write in response to your Regulation 28: Report to Prevent Future Deaths, dated 11th December 2020. Your concern was related to the environment Ms Shyama Vadwatee Rampadaruth waited in on the 13th April 2020.
At the inquest you raised the concern that Ms Rampadaruth waited 6 hours on a hard chair in the hospital waiting area rather than being allowed to go home while she waited for an evening dialysis session.
This event took place during the first peak of Covid 19 in April 2020 and the steps taken that day were an emergency measure. The team recognise that the lady’s experience of waiting for her dialysis session would have been better in her own home rather than in the hospitals waiting area.
I would like to assure you that since that day a significant number of actions have taken place to improve the experience of patients attending dialysis. All dialysis patients are now swabbed weekly so Covid cases are picked up on asymptomatic patients. This has allowed us to isolate and cohort Covid positive patients in a more planned fashion than Ms Rampadaruth experienced during the first wave and we have, so far, been able to keep all our covid positive dialysis on a single site. Additionally the renal team now have access to portable dialysis machines that were not available during the first surge in March and April 2020. This has given the team more flexibility in arranging urgent isolated dialysis when needed.
Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES Telephone:
Chief Medical Officer
Private & Confidential Ms Mary Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP
The dialysis service runs at over 99% capacity and so a lack of reserve does make managing dialysis safely through the pandemic extremely challenging. They are therefore actively planning to increase capacity and are seeking the resources needed to enable this.
Finally the renal team recognise that vaccinating their vulnerable cohort of patients is likely to be the best strategy to prevent future deaths among their vulnerable cohort of patients. They have been strongly advocating for this and I am pleased to say we have started vaccinating the dialysis patients when they attend for their sessions.
Thank you for bringing your concerns to my attention. I trust that you are assured that I have taken them seriously. I am very happy to discuss or clarify any of the above points.
Sent To
- Whipps Cross Hospital
Response Status
Linked responses
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56-Day Deadline
11 Mar 2021
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
On 3 July 2020, I commenced an investigation into the death of Shyama Rampadaruth, aged 86 years. The investigation concluded at the end of the inquest earlier today. I made a determination at inquest of death by natural causes.
Circumstances of the Death
Ms Rampadaruth had a number of co-morbidities, including renal failure, diabetes, hypertension, heart failure, asthma and cervical spondylosis. When she attended Whipps Cross Hospital for her routine renal dialysis on 13 April 2020, she was found to have a raised temperature and so was moved to a separate waiting area and dialysed with other patients suspected of having contracted COVID19. She was discharged home as usual, but deteriorated that night and was admitted as an emergency in the early hours of the following morning. COVID19 was diagnosed, she continued to deteriorate and died three days later.
Copies Sent To
, niece of Shyama Rampadaruth
, nephrologist, Whipps Cross Hospital
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.