Hana Elhamid
PFD Report
All Responded
Ref: 2015-0194
All 1 response received
· Deadline: 8 Jul 2015
Coroner's Concerns (AI summary)
Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic coma, with resultant trachea injury, directly causing death.
View full coroner's concerns
_ that this patient developed diabetes whilst on term Clozapine treatment and that routine blood tests for sugar in the blood are likely to have prevented events, the need for intubation treatment for a diabetic coma with resultant trachea injury following self -extubation, that directly led to the patients death
Responses
Noted
The Department of Health acknowledges concerns and explains existing NICE guidelines for monitoring patients on antipsychotic medication. NHS England is working with the Royal College of Psychiatrists to investigate patient safety incidents associated with Clozapine. (AI summary)
The Department of Health acknowledges concerns and explains existing NICE guidelines for monitoring patients on antipsychotic medication. NHS England is working with the Royal College of Psychiatrists to investigate patient safety incidents associated with Clozapine. (AI summary)
View full response
Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of Health Richmond House 79 Whitehall London SWIA 2NS POC3OOO 946771 Tel: 020 7210 4850 Mr A_ Walker Senior Coroner North London Coroner's Court 29 Wood Street Barnet ENS 4BE 6 JUL 2015 Jew W Uelku Thank you for letter of 13 2015 following the inquest into the death of Hana Elhamid: I was very SOrry to hear of Miss Elhamid'$ death and wish to extend my sincere condolences to her family: Although the medical cause of Miss Elhamid '$ death in 2014 was respiratory failure, you consider that if she had been diagnosed as having diabetes in 2012, then none of the other medical events, which ultimately led to her death, would have occurred. You out that there was an opportunity to test Miss Elhamid for blood sugar levels while she was in the care of the London Treatment and Rehabilitation Centre (LTRC), which would have revealed the diabetes at a time when it could have been treated and managed You raise the following concerns: that the patient developed diabetes when on term Clozapine treatment that routine blood tests for sugar in the blood are likely to have prevented events that led directly to Miss Elhamid'$ death: Iexpect any patient in a mental health setting to receive all appropriate care and treatment for mental and physical health conditions. Barnet; Enfield and Haringey Mental Health Trust (BEHMHT) confirm that it was recommended that Miss Elhamid start a trial of Clozapine in February 2009. In April 2009, Miss Elhamid was transferred to the Ashwood Centre in Croydon (part of the LTRC) where, I am told, she was not prepared to have blood tests taken and s0 the trial was not initiated. Miss Elhamid did not begin taking Clozapine until 2012, May ` your point long May
whilst in the care of LTRC. [ understand that LTRC could not provide you with records detailing blood glucose tests taken between 2012 and November 2012 as no such tests had been carried out: BEHMHT conducted a root cause analysis investigation following the death, which examined whether the clinical care and treatment at BEHMHT was to an acceptable standard and in accordance with policies and procedures You may wish to contact BEHMHT directly for further background information about this investigation and its outcome_ Clear guidelines, concerning the monitoring of patients who are using antipsychotic medication such as Clozapine, exist and are published by NHS Choices and the National Institute of Health and Care Excellence (NICE): The raised risk of developing diabetes when on Clozapine treatment is known. In addition, NICE'$ clinical guideline, Psvchosis and schizophrenia in adults: treatment and management (CG 178) advises that blood glucose is checked before starting antipsychotic medication; that the secondary care Mental Health service should continue to monitor this for at least 12 months or later if the person has not stabilised; and that GPs should continue to monitor this when responsibility is transferred t0 them. Your report has also been shared with NHS England. NHS England is currently working with the Royal College of Psychiatrists and the Prescribing Observatory for Mental Health to investigate patient safety incidents associated with Clozapine. Patient monitoring is included within the scope of this work: Should compelling evidence of system failures be found, then NHS England would support work to improve management and minimise harm. I hope that you find this reply helpful and I am grateful to you for bringing the circumstances of Miss Elhamid's death to my attention. S'4eee Ai L ALISTAIR BURT May
whilst in the care of LTRC. [ understand that LTRC could not provide you with records detailing blood glucose tests taken between 2012 and November 2012 as no such tests had been carried out: BEHMHT conducted a root cause analysis investigation following the death, which examined whether the clinical care and treatment at BEHMHT was to an acceptable standard and in accordance with policies and procedures You may wish to contact BEHMHT directly for further background information about this investigation and its outcome_ Clear guidelines, concerning the monitoring of patients who are using antipsychotic medication such as Clozapine, exist and are published by NHS Choices and the National Institute of Health and Care Excellence (NICE): The raised risk of developing diabetes when on Clozapine treatment is known. In addition, NICE'$ clinical guideline, Psvchosis and schizophrenia in adults: treatment and management (CG 178) advises that blood glucose is checked before starting antipsychotic medication; that the secondary care Mental Health service should continue to monitor this for at least 12 months or later if the person has not stabilised; and that GPs should continue to monitor this when responsibility is transferred t0 them. Your report has also been shared with NHS England. NHS England is currently working with the Royal College of Psychiatrists and the Prescribing Observatory for Mental Health to investigate patient safety incidents associated with Clozapine. Patient monitoring is included within the scope of this work: Should compelling evidence of system failures be found, then NHS England would support work to improve management and minimise harm. I hope that you find this reply helpful and I am grateful to you for bringing the circumstances of Miss Elhamid's death to my attention. S'4eee Ai L ALISTAIR BURT May
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
8 Jul 2015
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 the 9hh June 2014 opened an investigation touching the death of Hana Aisha Abd Elhamid 25 years old. The inquest concluded on the 7th 2015. The conclusion of the inquest was 'Narrative" , the medical case of death was Ia Respiratory failure 1b Tracheal Stenosis complicating laryngotracheal injury sustained during self-extubation during treatment for a diabetic coma
Circumstances of the Death
Miss Abd Elhamid was a patient treated for a mental health condition and it became necessary to treat her condition with Clozapine. It is likely that the diabetes was a complication of the use of Clozapine and routine fasting blood tests were not carried out which was a serious failure. It is likely that the diabetes had been developing for some time before Miss Abd Elhamid became seriously unwell whilst on a home visit. Miss Abd Elhamid was taken to the hospital on the 13th November 2012. There was a medical need to intubate Miss Abd Elhamid and during the process of waking Miss Abd Elhamid extubated herself: Although this is not unusual in these circumstances in this case the result was damage to the airway_ Many attempts were made to treat Miss Abd Elhamid at a specialist hospital where a tracheal stent was fitted. Miss Abd Elhamid became unwell with breathing difficulties and was admitted to_hospital on the 4th June 2014.A decision was taken to attempt to treat Miss May being
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) Abd Elhamid which encountered such difficulties due to the narrowed airway that Miss Abd Elhamid died. There was an opportunity to test for blood sugar which is likely to have demonstrated the presence of diabetes at a time where the diabetes would have been amenable to treatment_ There was therefore an opportunity to render care which if taken would have prevented the death.
Her Majesty's Coroner for the Northern District of Greater London (Harrow; Brent; Barnet; Haringey and Enfield) Abd Elhamid which encountered such difficulties due to the narrowed airway that Miss Abd Elhamid died. There was an opportunity to test for blood sugar which is likely to have demonstrated the presence of diabetes at a time where the diabetes would have been amenable to treatment_ There was therefore an opportunity to render care which if taken would have prevented the death.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.