RESPONSE TO REGULATION 28 CORONER’S REPORT TO PREVENT FUTURE DEATHS

1 THIS RESPONSE IS MADE ON BEHALF OF University College London Hospitals NHS Foundation Trust 2 REGULATION 28 REPORT This response follows a report by Assistant Coroner Dr R Brittain dated 27 January 2014. 3 INVESTIGATION AND INQUEST The inquest in question relates to the death of Umul Kelsum Anna AUDU who died at University College Hospital on 20 October 2013. Her inquest was concluded on 24 January 2014. 4 CIRCUMSTANCES OF THE DEATH On behalf of the Trust I have carried out a full investigation into the case and in particular examined the events around her transfer for imaging at which time a period of hypothermia is documented. Normal human body temperature in adults is 34.4-37.8ºC (93.9-100ºF). Hypothermia is defined as any body temperature below 35ºC (95ºF). Hypothermia is classified in 4 different grades with mild hypothermia relating to 32-35ºC (90-95ºF). There are 3 further grades below this and to put this specific case into context, the lowest temperature documented was 33.6ºC, thus classified as mild hypothermia. Your conclusion was that no adverse consequences occurred as a result of this period of hypothermia and that also represents my view. Based on documentary evidence at inquest you have noted that there was no transport heater available on the ICU to enable warming of patients whilst they are away from the unit. You have noted as a matter of concern that the lack of transport heater availability was not explained in the written evidence presented by the Trust. This had not been identified as an issue prior to the hearing and on reflection the statement provided on our behalf may have been misleading. The position in fact is that we do not use transport heaters within the Trust and we believe that this is in line with national practice. At present although transport heater devices do exist to prevent hypothermia, they are not routinely used for patient transfer in UK hospitals. Furthermore, there is no specific guidance from any of the Critical Care Society suggesting adults should be actively warmed with this devices during transfer for investigations. The current advice is that standard measures to avoid hypothermia are routinely used during transfer, as in fact occurred in this case. More specifically, MRI scanning (the investigation that the patient in question underwent) is even more problematic. Transport heater devices such as warming blankets contain metallic elements, which are absolutely contraindicated for use in the MRI environment, and indeed there are reports in the literature of patients being burnt in MRI scanners when such devices have been used. 5 CORONER’S CONCERNS As an organisation we are mindful of our duty to consider your report and indeed I have carried out a full investigation into the case.

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In reviewing the case, I have sought the advice of my colleagues in Critical Care at UCLH and discussed the case at our Divisional Clinical Governance meeting. In addition, the case was discussed in detail at our joint Critical Care Collaboration Group meeting at which all of the clinical leads at the ICUs at UCLH (UCH Tower, ITU, Heart Hospital at ITU and the National Hospital for Neurological Diseases ITU) attended. Our considered position based on these enquiries and the views of my colleagues is that at present we would not propose to change our policy and introduce transport heaters for the reason set out above. That is:

(i) We believe that standard measures to avert hypothermia will

protect patients from any significant harm and will avoid any

risk of future death

(2) Our current practice is in line with national standards

(3) There are positive contraindications to using such devices for

some investigations and their introduction could increase risk

to patients of harm. We will however be keeping the position under review. It is a complex issue and at present we do not believe simply introducing transport heaters is appropriate and, for the reason stated, based on our investigations we do not believe that a lack of transport heater availability in itself could give rise to a risk of future deaths. 6 ACTION TAKEN/TIMESCALE (1) We have carried out a full investigation. (2) We will keep this issue under review but at present would not propose

to introduce transport heaters for the reasons set out above. (3) We would be happy to provide further details regarding our considered

view if this would assist you. 7 THIS RESPONSE HAS BEEN PREPARED BY , Divisional Clinical Director, Critical Care, UCLH 8 DATE OF RESPONSE 24 March 2014