The first witness to give live evidence on Day 2 of David’s inquest was Dr Laura Chase. She gave an affirmation.
She told the court that she’s currently employed in Hull as a Consultant in Internal Medicine and Renal Medicine although at the time of providing her statement she was a Specialist Registrar in her 6th year of Postgraduate Speciality Training.
She confirmed to the coroner that she had had a chance to look at her statement in advance of giving evidence, and that she had been in court the day before so she agreed with his suggestion that she was familiar with the topics.
The coroner asked her to help him with the chronology, and tell him about her first involvement in David’s care.
LC: On the date of David’s admission I was working a night shift, 8pm to 8am as the Resident Medical Officer, i.e. the medical registrar, my role that evening was bridging treatment for patients between the Emergency Department and the Acute Medical Unit. At 8pm took handover from colleague on during the daytime, initially had to review patient in the ED, my normal practice would be then to go thru to the Emergency Department, have a walk around the department, see what else was happening… any additional problems. it was during that walk around I encountered Dr Young 9 to 9:30pm if I estimate, he’d mentioned David had been admitted and the circumstances of his admission. We had a discussion about particulars.
She told the court David had been on the floor for an unknown period of time, likely several days and he was clinically dehydrated.
C: You heard Dr Young’s evidence yesterday in so far as he spoke to your predecessor, the day shift registrar and there would be a handover. Did you receive a handover from your day shift?
LC: I did not
C: Is it usual to not receive a handover?
LC: I received a handover from my colleague but he had not mentioned David
Dr Chase told the court her usual practice was as she was attending the Emergency Department anyway, to see a patient in the resus area, that she would visit majors as well and see if they had any patients they were worried about.
LC: I was aware David was found after an unknown period of time, he was clinically dehydrated. I was aware of his history of autism and the agitation he presented with. Dr Young explained it was necessary to provide him with sedation in order to instigate medical treatment for the aforementioned dehydration. We’d had a discussion about the clinical particulars, I was aware he was dehydrated and hypotensive, did not have full NEWS score available to me at time…. But he was receiving initial treatment for that, which was appropriate in my opinion. There wasn’t an overt clinical concern that I needed to review him immediately and we agreed I’d review him at some point during that shift.
C: OK, so again clarification. In relation to he was receiving initial treatment, appropriate in your opinion, was not overt clinical concern. Help us with the information that sits below that.
LC: As discussion, he was hypotensive, clinically impression he was dehydrated, initial treatment for that was replacement by IV fluids, and you would expect to provide fluid challenge and see what response to that treatment was in the first instance, and I felt that was appropriate.
C: You mentioned the NEWS scores and heard our interactions with Dr Young about different features are that can generate the score… you have said you did not have full NEWS scores but could judge. Do you think your opinion would have been advantaged by looking at the NEWS scores or?
LC: I think it would have only confirmed my judgement, yeh
The coroner repeated her evidence back to her to check. Dr Chase added that at the time of her conversation with Dr Young David’s observations were “relatively static” and therefore there was no immediate pressure for her to see him straight away.
She told the court David had already been seen by a senior decision maker, and he was receiving active treatment. She said she agreed with Dr Young that David would have been an appropriate referral for Intensive Care in the event the initial therapy failed.
Asked by the coroner how things were left between her and Dr Young she said it was her usual practice that if they had a concern they would update her and if there was any change in David’s clinical situation she would review him more urgently.
The coroner then asked Dr Chase if she were able to tell the court about the recommended 30 minute observations of David on the nursing system.
Dr Chase said that nursing staff used an electronic system of Early Warning Scores and it automatically populated recommendations in terms of frequency of observations. She said in terms of how it was used in the department, nursing staff each had their own electronic devices on which they would record the early warning scores, and they generate an alert at the time the observations are due again. Dr Chase added the caveat to that is in a department where a nurse is looking after multiple patients, they may be engaged in other clinical duties at the time observations were due.
The coroner said that Dr Chase was dovetailing Dr Young’s opinion that the missed observations constituted a missed opportunity in David’s care. Asked what the reason was for thirty minute observations Dr Chase responded “In that situation is to detect potentially early deterioration of a patient and a change in clinical status, that might alter their management plan”.
Returning to the chronology, the coroner asked Dr Chase what her next involvement with David was. She responded that Dr Young had called her about half an hour after they’d spoken to update her with David’s blood test results which confirmed David had an acute kidney injury. She said she “agreed again the current prescribed therapy was appropriate and I hadn’t suggested any further actions at that time”.
The coroner asked her what her thought process was in relation to David being referred to Intensive Care at that time. She told the court she’d have remained of the opinion if his initial therapy had failed than a referral to Intensive Care would be appropriate, adding David was still early into his initial therapy.
LC: It would be reasonable to challenge someone with two litres of IV fluids before declaring they’d failed that therapy.
C: Help us, he was referred later down the line?
LC: He wasn’t referred to Intensive Care. Intensive Care attended the cardiac arrest.
C: In terms of the therapy failing, what would that look like?
LC: In patient persistently hypotensive despite being given appropriate volume of fluid, I’d define as blood pressure of less than 90 systolic.
Moving back to the chronology the coroner told Dr Chase that her next involvement with David, after the conversation she had about David’s blood results with Dr Young at about 10pm, was at his cardiac arrest at 02:49. She confirmed that was correct.
Asked by the coroner how long she expected it to take for David’s “initial therapy” to work through, Dr Chase responded that typically 2 litres of fluid can be given within 2 hours and often it would be sooner than that. She added there may be reasons to slow that rate down, if there are concerns someone might be at risk of a reperfusion injury, or they had an underlying cardiovascular comorbidity.
In response to questions from the coroner Dr Chase confirmed she was not contacted by any other member of the Emergency Department about David, including once Dr Young went off shift.
She explained her involvement in David’s CPR.
C: Yes, and just again clarification arising from what you’ve said, obviously he’d gone to the Acute Admission Unit and you weren’t aware of that?
LC: Yes
C: Help us with the rationale to take him to AAU against an ICU?
LC: The decision in terms of admission pathway is usually made very early on in the arrival at … essentially determining does this person need to be under the care of medical speciality, surgical speciality or are they going to be discharged home. So, the admission pathway for medicine, the default position would be someone would go to the admissions unit.
C: AAU?
LC: AAU, unless indication they needed to go elsewhere. So, in terms of the decision to take him to the AMU rather than ICU, think would have been informed on what David’s response to treatment would have been. Had he failed therapy in the A&E as discussed, a referral to ICU would be made. On the assumption that therapy was going to work, otherwise a bed was being made on the admission unit, as Dr Young gave in evidence yesterday, he arranged that provisionally with the bed managers.
C: yes, in terms of the Acute Admissions Unit, Dr Young gave some evidence yesterday in relation to the targets as it were, to get people off the Emergency Department. Is the AMU a way of moving someone off A&E but still in the same territory?
LC: Yes
C: Is Acute Admissions not Intensive Care?
LC: Yes if transferred to AMU from the Emergency Department within 4 hours, that is meeting the target
C: And in relation to you not knowing David had gone to AAU, is that something that surprises you?
LC: Under normal circumstances if patient of low acuity and no imminent medical concerns then I’d not expect to be informed, many, many patients are admitted to the AMU, I wouldn’t have time to do my duties… Part of role of medical registrar is to be aware of those people who should be reviewed by a senior member of medical team prior to admission on AMU, because potentially may need to go to another venue, i.e. Intensive Care
C: OK, do you have any observations in relation to your view about whether David ought to have been brought to the ICU?
LC: So I would normally expect, speaking in generalisations, if patient had high NEWS score, prior to transfer the A&E would discuss it with me so I had a chance to review them.
Dr Chase said she would expect patients to stay in the Emergency Department and be reviewed by herself, so that she had the opportunity to make decisions and liaise with appropriate senior clinicians, and if appropriate after her review they could be transferred to the Admissions Unit.
The coroner said it was not a criticism but she had given an almost theoretical answer.
C: Your answer really affirms the situation as it were. What would be your view as to whether David should be admitted to ICU, do you see what I mean?
LC: At that point, if his NEWS score was still 8, he had received at least 2 litres of IV fluid and his blood pressure was no better, I’d have reviewed him in the Emergency Department and potentially had a discussion with Intensive Care at that time, had it been appropriate.
As I say there are a number of variables there, the particulars at that moment in time, I’m not certain of.
C: To follow that through to the next place, David did get to a stage… where his NEWS score was still at 8, albeit it fell to 4 at 01:19, and he had received his 2 litres of fluid, I say no better advisably, in terms of are we standing on turf of what your answer has given, it looks like we might be. I know your evidence is you didn’t have any further dealings because you went to AAU.
It sounds like the evidence you’re giving, you are in the turf …. It sounds like practical application of the evidence is yes, he didn’t go to ICU.
You don’t know what you don’t know… facts are you weren’t aware he was in the situation he was in. Is that fair?
Dr Chase: Uh hum
The coroner said he had interrupted Dr Chase’s chronology and asked her to talk about the period after David’s cardiac arrest.
She said that the Intensive Care Registrar and another medical registrar who was on duty but not covering the Emergency Department was present at the early stages of David’s cardiac arrest.
LC: As a discussion between the three of us essentially, assessing the information we had in front of us and David’s status at that time, agreement between us is unfortunately he was not showing evidence his outcomes were likely to be favourable
C: Yes
LC: So at that time an ICU admission would have been futile
The coroner asked Dr Chase to form a view of what an earlier intensive care admission would have done for David.
C: What would you do with someone in that situation? He’s failed initial therapy is that fair, appreciate you didn’t know at time.
LC: I didn’t know at the time, would temper that with next set of observations in the Admission Unit had shown his blood pressure improved at that point and his temperature was better
C: It’s a mixed picture isn’t it?
LC: Mixed picture, could extrapolate things were improving and he had responded to treatment. If only judged observations done before that, if situation he’d already had that volume given, no further ahead and if he had been reviewed at that time, rightly so the position would be do we need to ask for an Intensive Care Opinion and does he need taken, …pending intensive care decision, sometimes on one hand they might agree to take him to Intensive Care Unit for blood pressure support, inotropic support; they might have said give him more fluids.
The coroner checked that Dr Chase was saying it was at the discretion of the Intensive Care Clinician, she was, and that there were things they could do on Intensive Care that could not be done in the Emergency Department. She said that inotropic support medications to support blood pressure are only provided on High Dependency or Intensive Care settings.
Dr Chase added the other intervention that might be expected in ICU is a potentially invasive blood pressure monitoring catheter in a person’s arterial line. The coroner checked that wasn’t something that could be provided in A&E or on AAU, it wasn’t.
The coroner read the opinion from Dr Breen’s report, he’s the court appointed expert on Intensive Care.
C: He gives his opinion. There may have been some support that could have been offered on the Intensive Care Unit, and admission to ICU would probably have prevented the subsequent cardiac arrest Anything to say about that?
LC: Agree additional options for physiological support and monitoring on ICU not available in the Admissions Unit. An admission to Intensive Care and more frequent monitoring or potential interventions available there, may have prevented a cardiac arrest, however had he proceeded to have a cardiac arrest I don’t necessarily think the outcome would have been any different
C: Just help us with that last bit
LC: Reason I say that is CPR was started very quickly on AAU and was delivered to a high standard…. If he had an arrest on ICU the interval before starting CPR would have been very similar.
The coroner asked Dr Chase is there was a difference in the level of monitoring provided to someone in ICU and A&E. She confirmed that there was and that was based primarily on nursing ratios.
LC: On Admissions Unit the ratio may be 6 to 12 patients per nurse, on Intensive Care Unit would expect 1 to 2 patients per nurse
The coroner then asked Dr Chase her view on the pathologists findings and David’s cause of death being given as 1a) bilateral pneumonia. Dr Chase said as per Dr Young’s evidence yesterday, there wasn’t an initial concern about David’s respiratory system at the time he presented to the ED. She said his respiratory rates were relatively stable, barring one outlying measure at 24 per minute, others were in the teens.
LC: Typically, my experience for person suffering severe bilateral pneumonia, that’s the cause of their demise, would expect them to show evident signs of respiratory distress. Raised respiratory rate can be part of respiratory distress, but more evidence from the end of bed that someone may look cyanosed, blue discolouration of their skin, may be using ancillary muscles for respiration, including muscles in their neck… is something can see from a distance, they may change their physical position in order to make the process of breathing easier. As Dr Young explained there were no signs of respiratory distress there.
I would also expect for significant bilateral pneumonia, a greater degree of hypoxia would be noticeable. David previously required an Intensive Care Admission, ventilation for pneumonia… as discussed, he was not hypoxic.
Dr Chase added that she would have expected different blood results and biochemistry from David if he had a severe bilateral pneumonia.
Questioned further by the coroner she offered the following view on cause of death:
My feeling based on my knowledge of case and results I had available to me at time was a severe metabolic disturbance. A metabolic disturbance due to a prolonged period of reduced perfusion, as a result of hypotension. That was evidenced by the blood gas we had obtained during the arrest attempt, demonstrating PH of 6.88.
She said that she would have given 1a as Severe Metabolic Acidosis due to 1b Hypovolemia. After some further discussion, it was over to Ciara Bartlam to ask questions of Dr Chase on behalf of David’s family.
CB: I’ll just ask questions on this last bit first before we go into the break, firstly is what you said about the blood test and physical examination of David showing no sign of respiratory distress. Would you agree with statement there is only a record of David being observed and his respiratory state being observed once on AAU, at around 01:30 by nurse who initially assessed him?
LC: I agree
CB: So good one hour period where no one has observed his respiratory function?
LC: I’d agree
CB: In terms of what is going on for David, he has been administered with Midazolam fairly soon after admission to the ED, then later Lorazepam. Could Lorazepam in your view mask symptoms of respiratory distress?
LC: Lorazepam can reduce respiratory distress, yes.
CB: In terms of pneumonia would you agree that’s a leading cause of death for people with a learning disability?
LC: To my knowledge I’d agree
CB: And therefore should be treated with a high index of suspicion in this group, and in David?
LC: I agree
Ciara Bartlam takes Dr Chase to the pathology report and reads a section relating to David’s respiratory system.
CB: Both lungs show evidence of pneumonia features involving all lobes along with congestion and oedema. Thick mucous is noted in the small airways and exuding from the cut surface of the lung parenchyma of both right and left lower lobes. The lung parenchyma is markedly friable. The pulmonary vessels are unremarkable. In terms of evidence of pneumonia would you agree that’s set out in this report firstly?
LC: That is what’s written
CB: In terms of a reasonable explanation for those findings, would you agree in those circumstances the pathologist is better placed than you to say what they show?
Dr Chase said she was not a pathologist and she was postulating about what might be found in the lungs.
CB: To be very, very clear Dr Cooke is saying on the balance of probabilities 1a) bilateral pneumonia. All you’re able to say is the possibility of an alternative?
LC: Yes because as I say I didn’t actually physically examine David until after his cardiac arrest, I can’t say… he didn’t have a chest xray done at the time, don’t have radiological evidence, can only provide hypothesis based on my knowledge and review of the records we have
CB: Yes, the blood gas and blood results is 9pm, a good five hours before the arrest.
LC: I was referring to the blood test at the time of arrest.
CB: I don’t think I have any further questions on cause of death
At this point the court adjourned for a mid-morning break for 10 minutes. We returned at 11:25 and it was back to Ms Bartlam for her questions for Dr Chase. She thanked her for giving evidence and said she would try not to repeat earlier questions.
CB: That first conversation you had with Dr Young isn’t recorded anywhere contemporaneously. Do you agree?
LC: Yes
CB: Should it have been?
LC: Not necessarily, often practically speaking it’s a case patients are alerted to me, plan who needs to be seen but there isn’t a formal handover process or documentation process necessarily for that, unless the physician in the ED may choose to add that to their documentation to say discussed with Medical Registrar on call, otherwise can be quite flexible and fluid
CB: for understanding, you are the person who is accepting David on to the AAU is that right?
LC: No, as I already indicated, in terms of admission pathway from the Emergency Department, at time reviewed on ED there’s decision made whether an individual needs to be admitted under medical specialty, or surgical speciality or they’re for discharge. It’s determining that pathway they need to go along then.
Once that has been determined, medical admission don’t need to be accepted by medical registrar. Those patients where clinical concern or decision needs to be made, are usually those escalated to medical registrar. You’re highlighting something needs to be done sooner, than otherwise would have been undertaken as matter of routine.
There was then a discussion about the clerking process when someone was admitted to the Acute Admissions Unit. Dr Chase told the court when David was triaged on his arrival on the AAU his initial observations at 01:19 gave a NEWS score of 4, so he would require observations at a minimum 4 to 6 hourly. She said there wasn’t a reason for nursing staff to escalate David based on the NEWS scores.
Ms Bartlam turned to Dr Chase’s statement and asked about David’s NEWS scores, checking if someone’s observations were stable at 1 or 2 on NEW score it may not be a cause for concern, but if they were stable at 7 that may be a cause for concern. Dr Chase agreed.
She told the court she didn’t have David’s NEWS scores available to her when discussing him with Dr Young.
LC: I was aware his blood pressure was low and he was hypothermic, my expectation is someone who is physiologically unstable in some respect, in this case cardiovascularly unstable with low blood pressure, I’d want to see improvement of that before he was moved to the Unit, and if there hadn’t been I needed to be involved.
CB: You’d agree with NEWS scores until 1am there was no marked improvement?
LC: There was no marked improvement
CB: You were aware David was sedated to achieve IV access. You were aware of the Midazolam?
LC: I was aware of Midazolam
CB: Were you aware of any point prior to David’s arrest that Lorazepam had been administered?
LC: No
CB: Are you able to say whether anybody from the nursing staff or anyone else on the Admissions Unit was aware of that fact?
LC: No
CB: In terms of the way in which Lorazepam had been administered, we know 2mg administered intravenously. Can you helps us understand whether that’s a small dose, large dose, usual administration?
LC: Dose of 2mg probably fairly standard, not particularly large dose, can use for treatment of seizures, may use larger doses 4mg or sometimes more, so fairly standard dose. Lorazepam being given intravenously is fairly usual practice in an acute medical environment, ED or the Admissions Unit.
Dr Chase said she agreed that the administration of sedative, given its possible impact on respiratory function, needed to be closely monitored.
CB: Would you agree in order to effectively monitor it, you need to know it’s been administered?
LC: I agree
Ciara Bartlam asked if Dr Chase had known that Lorazepam had been administered 30 minutes before David’s arrival on the AAU, what she would expect to happen. Dr Chase said she did not know if the nurse who received David on the unit was aware he had received that sedation.
LC: With respect of the actions taken, perhaps might make an action plan to increase monitoring in that situation
CB: I don’t think it is controversial that Lorazepam isn’t mentioned anywhere in the nursing assessment at all
LC: No, as I say I don’t know what was handed over verbally
CB: You described what should happen in your view with a NEWS score of 7 and a failure to respond to fluids. Would you agree consideration of Intensive Care, or staying on the Emergency Department is more important still with the context of the benzodiazepines recently being administered?
LC: I would, yes
This is very, very tricky actually. If you’d been aware of all that information at the point David was transferred to AAU, would you have put a hold on that transfer?
LC: Yes
CB: In addition, we know nobody had examined David’s chest. On your review of David in the Emergency Department would you have examined his chest?
LC: Yes
CB: And you’d accept that at that point it would have been possible. There is no suggestion of agitation pre-transfer?
LC: I accept that
Ms Bartlam said she would move on to discuss the initial assessment of David on his transfer to the Acute Admissions Unit. She took Dr Chase to a page in the Hull records, that was a handwritten note by a nurse Joanna, timed 01:45 on 13 January 2022, and asked her to read that to herself.
CB: We can see that the nurse, this is the nursing assessment, initial assessment undertaken on transfer to AAU. Is that right?
LC: Appears that way
CB: The nurse records David is drowsy, not in respiratory distress
LC: Yes
CB: In terms of him being drowsy, does that tell you anything on the scale of whether he’s alert, responsive to pain, anything like that?
LC: Drowsiness you may be between alert or responsive to voice. Someone tending towards sleep, but if we’re able to rouse…
CB: In terms of the other information we have here, referred earlier 4 days long lie, also refers to David’s learning disability, in terms of the knowledge of AAU, are they also aware of the dysphagia?
LC: I don’t think I was aware of the dysphagia
CB: You said you were aware of the earlier ICU admission?
LC: I was aware
CB: So three facts, long lie, learning disability and previous admission for pneumonia. Would you agree in AAU there also needs to be some suspicion about the risk of pneumonia in this patient?
LC: Absolutely agree
CB: In order to assess whether or not that was a fact, David’s chest needed to be examined?
LC: Yes
CB: There’s no suggestion his chest was examined on this occasion?
Dr Chase explained that this was a nursing assessment, and only a doctor would listen to a patient’s chest, so that would only happen when David was seen by a clinician. She said that the nurse would not have requested that David be seen based on his NEWS score. She told the court that patients admitted to the AAU are typically seen on a first come, first served basis.
Ms Bartlam then asked Dr Chase about a section in her statement about the plan for her involvement with David.
CB: In your statement, you write as David’s observations were stable at the time … due to other clinical responsibilities to other unwell patients… I did not review David in the Emergency Department prior to his transfer to the Acute Admissions Unit
LC: Yes
CB: That’s about the ED?
LC: Yes
CB: It seems you appreciated there was a need to review him though, if his NEWS score remained high or there were any matters of concern?
LC: Yes, as I explained earlier that had been my agreement with Dr Young. I’d review him prior to his transfer to AAU if he was still needing. He was on my list pf patients, I made a judgement of who I needed to see first. At time conversation with Dr Young he’d just received initial treatment … understanding if there was a change he’d discuss with me and we’d reassess.
CB: On AAU David wasn’t seen by a clinician before the cardiac arrest, that’s 1 hour 40 minutes?
LC: Yes
Ms Bartlam asked about capacity on the ward and Dr Chase explained its an approximately 45 bed unit and overnight they might expect approximately three quarters of the capacity of the unit to be changing, could have 30 admissions a night. She explained the medical staffing would be herself, as registrar also covering the Emergency Department, that there would be at least one more senior medical trainee in their second year of postgraduate training, and two more junior foundation year doctors.
She told the court on an average night patients were likely to wait around 3 or 4 hours to be seen by a clinician on admission to AAU.
CB: Given you said there’s a potential 3 or 4 hour wait to see a clinician, is it fair to say AAU is not the place for someone who is acutely unwell?
LC: Acutely unwell patients are managed on the AAU, but that medical review, and ratios in terms of nurses to patients and impact has on frequency of monitoring unless indicated, is part of the reason why there’s that safety net of the medical registrar reviewing more unwell patients prior to their admission to the AAU, or make decision that they need to be in higher dependency area or intensive care.
CB: Turning to NEWS score at 01:20 you heard what Dr Young said yesterday about change between 8 and 4 would to him be quite implausible on the facts he knew about David, and that would have given him reason to think what’s going on here. Would you agree a drop from 8 to 4 is quite substantial?
LC: It’s a substantial improvement in NEWS score, absolutely.
CB: In terms of what happens to David he was last administered fluids at 00:10 and wasn’t administered fluids at all on AAU, is that correct?
LC: From my reading of the records I don’t think further fluids were prescribed
CB: So that drop isn’t a result of any treatment David is receiving?
LC: As alluded to before may have been a genuine improvement because he’s had certain amount of volume replacement, his blood pressure had improved to systolic 90 at that point and his [missed] had improved
CB: and his heart rate has also increased?
LC: Yes I agree
CB: Would you agree NEWS score is only certain help to clinician and needs to be taken alongside examination?
LC: As with all examination you gain useful information from physical examination
CB: Would you agree a full physical examination which didn’t happen in this case?
LC: Well it didn’t happen because he’d not been seen
CB: In what you said about respiratory secretions… you said can also lead to pneumonia. Would you agree to work out how prominent a feature that was, that would also require a chest examination?
LC: Yes
CB: In terms of David’s presentation and the weakness he was experiencing, you’d have heard yesterday of course, it was said to Dr Young about Keri’s evidence, in 2017 when David had pneumonia he had a cough, wasn’t present on this occasion, she wondered if that was due to his weakened state.
LC: Umm
CB: Would you concur some of what you described may not of occurred on this occasion because David was just so weak?
LC: That’s right
CB: In terms of David’s presentation at 01:10 that’s assumption of what happening in terms of his respiratory system, was just an assumption because no examination?
Dr Chase agreed and gave a fuller answer which I missed, apologies.
She agreed with a suggestion from Ms Bartlam that ICU would allow for enhanced monitoring, as part of a package of treatment. She added that it was “part of the package but in itself it has no therapeutic impact”.
CB: Jumping forward to the registrar at the arrest at 03:10, were they aware of the administration of Lorazepam?
LC: I wasn’t aware, so I don’t think they’d be aware. They’d have been aware of benzodiazepine earlier in the evening, that’s what I had.
Ms Bartlam took Dr Chase to Keri’s statement, that had been read to the court yesterday, and read an extract before asking further questions.
CB: I recall asking if there were any reversible causes, for example, had he been given too much sedative medication and did this need reversing, and the doctor explaining this said this was not the case as David had received Lorazepam in the Emergency Department and the effects of this would have worn off by now.
In terms of what Dr Young says about Lorazepam in his statement he said peak plasma concentration is usually about 2 hours. Would you agree with that?
LC: I agree
CB: It was administered at 00:25, cardiac arrest roughly 2 hours later at 02:50, so would you agree Lorazepam could have been the cause for that cardiac arrest?
LC: Don’t believe would be the sole cause but could have been a factor.
CB: Could it have been the factor that tipped David over the edge?
LC: Again it’s a factor. Probably the prevailing abnormality in my opinion was he was acidotic, his blood gas was quite acidic and in situation often find haemodynamic instability. Consider more likely to be the main route cause rather than the Lorazepam, but Lorazepam probably was a factor in that.
CB: Thank you, that’s very helpful. Breaking that down, multiple factors, so we have acidosis contributing, that’s in your view more than minimally contributing on the balance of probabilities, to the cardiac arrest?
LC: Yes
CB: Lorazepam is also more than minimally contributing, albeit less than acidosis?
LC: Yes, potentially
CB: You said potentially, is it on the balance of probabilities likely to contribute?
LC: Yes
CB: In those circumstances is it concerning to you that information was not passed on to AAU and David’s condition wasn’t monitored, in light of that sedation?
LC: As I said I would have liked to be aware of that, prior to his transfer
CB: At that point after the cardiac arrest the decision is taken with Keri this is very sadly an end of life situation. Keri does raise the issue of Flumazenil, which is I understand a reversing agent for Lorazepam?
LC: Yes
CB: In light of the evidence you’ve given do you agree that ought to have been administered to David as it were probably more than a minimal cause?
LC: In situation at that time Flumazenil would not have changed the outcome because David had already suffered the cardiac arrest, and was already showing signs not likely to survive. In that situation it was already too late to get any benefit from it.
CB: So something that could have been done before the cardiac arrest but not after, in your view?
LC: Yes
Ms Bartlam asked about the decision not to give David fluids or antibiotics after his cardiac arrest and Dr Chase said from her recollection, it was not documented, but during the course of their conversation with Keri, David’s appearance was changing.
LC: The feeling of Dr Shah [?] and other junior doctors who were present was perhaps his death was more imminent and therefore in that situation again treatments such as fluids and antibiotics were unlikely to change the outcome.
CB: Would you agree best interest decisions like that need to be recorded?
LC: I would agree, yes
Ms Bartlam then took Dr Chase to the opinion of the court appointed Intensive Care expert, Dr Breen, who had concluded that an ICU admission would probably have prevented David’s cardiac arrest.
CB: Given what we have just discussed about Lorazepam and close monitoring on ICU, would you agree where he says it probably would have prevented cardiac arrest, that that is correct?
LC: It’s clearly very difficult to say, on the balance of probabilities, it probably could have prevented his cardiac arrest
CB: In addition Dr Breen says at 4.27 that the mechanism of David’s decline cannot be ascertained from the notes. He may have had a sudden cardiac arrest or suffered gradual physiological decline due to hypotension or hypoxia. I consider the latter to be the more likely scenario, as his medical history, ECGs and electrolytes did not indicate any abnormality that would herald a sudden cardiac event. Do you agree with that statement?
LC: Yes
Ms Bartlam turns her back to check there is nothing arising for David’s family and has no further questions at 12:03.
It was then over to Sara Lyle for Hull University Teaching Hospitals NHS Trust to ask questions of Dr Chase.
SL: I’ll start, because I’ve got the page open, its page 11 of Hull Records, it’s in relation to the Lorazepam. This is the medical record completed in the Emergency Department, would this record had been transferred with the patient when he was transferred around 01:15
LC: It would have been
SL: So, although you weren’t aware of this information, is it likely the nursing staff would have been aware of this information?
LC: They would have had it to hand at least
SL: Yes. You can’t say whether that was reviewed, it would have been on the AAU with the patient?
LC: It should have been
Ms Lyle asked Dr Chase about the dose of Lorazepam given to David (2mg) and she said it was a fairly standard dose and that she would expect it to have a sedative effect at that dose.
SL: Therefore, just in relation to the effect that would have had on the respiratory system, how sure can you be, on the balance of probabilities, that would have had an effect in terms of the cardiac arrest?
LC: At 2mg I’d be surprised if it had a severe respiratory depressive effect that it led to a significant enough hypoxic insult to lead to cardiac arrest
SL: So therefore, although previously you’d indicated to my learned friend when the questions were asked, that would have had an effect in terms of cardiac arrest, are you now saying it might have had an effect rather than it would have?
LC: My statement is as before, as a factor, particularly where someone is already compromised, it can conceivably on the balance of probability have some effect, and it probably did have some effect.
SL: But the overall impact, is that something you can’t say?
LC: Yes
SL: You did mention as well in your opinion this was multifactorial?
LC: Yes
Ms Lyle then asked Dr Chase about the Nerve Centre system used by nurses and she again confirmed that the system would generate alerts for the nursing staff to conduct observations.
Ms Lyle then asked Dr Chase to talk the court through the fluid chart document.
SL: You can talk us through it actually. What does that fluid chart illustrate in terms of when treatment started and each of those intervals?
LC: This is the prescription for the intravenous fluids done by Dr Young. He was prescribed in total 3 litres of 0.9% sodium chloride, of which the first three bags were warmed.
The prescriptions were actioned and started shortly after 9pm in the evening of 12th. First two bags, one litre, given stat, run through as quickly as can get through the cannula. The following one litre given over 2 hours, subsequent 1 litre over the following 4 hours.
SL: So therefore, if we look at that last entry, as in start 00:30 hours, that would the time that bag has stared?
LC: Yes
SL: How long would that have taken?
LC: Prescribed to be given over 2 hours
SL: So that would take us to 02:30 in the morning?
LC: Yes
SL: So the point at which David was transferred to AAU he was still receiving that treatment?
LC: At the point of transfer
SL: That was the period we, at the Trust, were assessing him at that point to see whether active treatment made a difference?
LC: That’s the point where assessment should have take place, after 2 litres.
SL: So when we are talking 2 litres, are we talking 02:30 or are we talking at 11 o’clock at night?
LC: So, the previous prescription up to 2 litres of fluids was due to finish at midnight. That’s the point at which he should have been assessed.
SL: Yes, at that point clearly a decision has been made, because further fluids were prescribed at that point?
LC: I’d take a view all of these fluids were prescribed at the 9 o’clock time.
SL: You would have expected a review 2 hours later, so 11 o’clock?
LC: I’d have expected a review after the first 2 litres were completed
SL: There’s no indication from that when they were completed. We’d expect that to be over 2 hours?
LC: Based on time that 4th line had been started 23:00 hours, was due to finish an hour later, I’d expect that to be at midnight.
SL: Sorry it took a long time to get there, but that is very helpful. So, we know Dr Young was involved in the care to an extent around midnight because the Lorazepam was also prescribed at that point?
LC: Yes
SL: So, there’s a further bag also prescribed at 00:30 hours. So that point, active treatment is still undergoing at the point he’s transferred at 01:19 hours?
LC: Yes
SL: So, when we look at numbers in observation chart, your page 56 and 59, we see then just before the administration at 00:48, just started the 5th bag at that point, is that right?
LC: Yes
SL: You’ve already indicated was slight improvement at that point in relation to temperature?
LC: Yes
SL: And a slightl improvement in systolic, but very slightly improvement?
LC: A slight improvement in his systolic blood pressure, but would ideally want to see his blood pressure above 90 systolic
SL: Then see 01:19, we do then see that improvement, is that right?
LC: His blood pressure at 01:14 is 92 systolic
SL: So at that stage there has been that improvement, but that’s after 2.5 litres of fluid?
LC: Yes
Ms Lyle then asked Dr Chase about the role of the admissions co-ordinator and how they work within the Emergency Department and AAU and transfer of patients, but first discussed whether she considered David’s treatment had failed in the ED.
SL: Forgive me but I understand your evidence to be, you had discussion with Dr Young, indication at that point was he’d be transferred to AAU at some point?
LC: Assuming his initial treatment didn’t fail
SL: Are you of the view the treatment failed?
LC: So, I’m of the view he hadn’t had an ideal response to his treatment, but the direction of travel, though it was very modest, was encouraging.
SL: Could that have been down to for example the long lie and period of potential dehydration David had suffered over those 4 days, as to why it may have taken a little longer in this case?
LC: Couple of factors, some touched on yesterday. He probably has quite significant volume deficit, probably in excess of 2 litres given he was without food and fluids for an extended period of time.
He was also being rewarmed, as alluded to, sometimes process of rewarming leads to relaxational dilation of peripheral blood vessels, by reducing systemic vascular resistance and that can lead to fall in blood pressure.
Along with that volume deficit you’ve also got slightly counterproductive process, you also need to account for, that might explain why that resuscitation was taking [can’t hear]
SL: In layman’s terms the rewarming would naturally reduce the blood pressure?
LC: Yes
SL: So, you’re fighting against the blood pressure reduced by dehydration, and effects of treatment could also reduce blood pressure?
LC: Yes, the effects of the treatment for his hypothermia. By rewarming him you’re lowering his blood pressure as you’re trying to raise his blood pressure with fluid replacement.
SL: And that can delay the process?
LC: yes
SL: Thank you
Ms Lyle then returned to ask about the process of allocating beds and what should happen once a bed is ready, before a patient is transferred.
LC: What should happen to my knowledge is the A&E coordinator at that time, should ask the A&E nurse looking after patient, in this case David, to do a set of observations to check that patient is stable and ready for transfer and there isn’t any other immediate treatment that needs to be given. If those are satisfied ideally the nurse, or an auxiliary nurse with a porter, will take the patient around to the Admissions Unit. On the Admissions Unit they should handover the clinical information to the nurse looking after that area essentially.
SL: We know observations at 01:19 were carried out by a nurse on AAU?
LC: Yes
SL: So, triage assessment was carried out at that point?
LC: Yes
SL: And as already ascertained he’d have still been receiving active treatment at that point because would take an hour for those fluids to be administered from 00:30?
LC: Yes
SL: So based on the information we had, still receiving active treatment… appeared to be having some indication of improvement based on observations. At that point was a referral to ICU clinically indicated?
LC: Based only on observations as a snapshot?
SL: Based on the facts we have
LC: Based on this snapshot, and someone being treated for volume depletion, I wouldn’t have said on basis of these observations an ICU admission was necessary
SL: Ultimately, let’s talk about that, there’s a difference between ICU agreeing a patient would be admitted, and an ICU referral?
LC: Yes is a distinction
SL [Missed question, apologies]
LC: Discussion of ICU Outreach Team… can refer to ICU Consultant, but ultimately they are decision makers as to whether or not someone is admitted to ICU
SL: Distinction between someone making referral and decision of whether someone is going to be admitted, they are very different. So, basically you can make an ICU referral but that does not ultimately mean that patient will be admitted to ICU?
LC: No clearly, ICU have their own agenda in some respect. They are looking after a very finite resource of high dependency beds. They have quite intimate knowledge of what their capacity is, bed capacity and nursing capacity.
Sometimes ICU can’t take patient or might be limited in what can offer a patient depending on staffing. Essentially the decision about whether someone is admitted and referred to Intensive Care Unit lies with the Intensive Care Registrar, who will liaise with the Intensive Care Consultant.
Sometimes all they need to offer is advice end support, continue what doing and we’ll check in, if things don’t improve will review again.
Sometimes they might review and agree this person needs escalation of care or something can only be provided in an Intensive Care Unit.
SL: You very kindly assisted with what additional treatment they could be offered. That additional treatment you assisted the learned coroner with, is that likely to have been administered or that plan changed if somebody is still receiving active treatment for fluid resuscitation at that point?
LC: They can occur in tandem
SL: They can?
LC: Yes. You might find someone you’re fluid resuscitating that’s not responding… they may continue that treatment but add in additional measures such as inotropic support.
SL: Of course, that would all be speculation in relation to what the ICU department would have provided that advice or not?
LC: Yes
SL: Is it likely they would have said let’s have a watch and wait scenario here and see what treatment plan results would produce?
The coroner interjects to say he has concerns with that question and he imagines Ms Bartlam may too. Ciara says that it risks taking this witness out of her expertise.
SL: Just following on from that, I may not be able to ask question, I apologise sir, might be a question for Dr Breen. What effect would that have had, do you know, on this particular patient if it was administered?
LC: The inotropic support?
SL: Yes
LC: They raise blood pressure by causing constriction of blood vessels, so it’s another measure by which you can raise blood pressure
Ms Lyle then asked about Dr Chase’s thoughts on cause of death, she reiterated that she thought it was a metabolic disturbance related to David’s low blood pressure and volume disruption, as opposed to the pneumonia being at the forefront of his presentation.
SL: You were asked questions by my learned friend just in relation to pre transfer NEWS being over 7, a failure to respond to fluids and the Lorazepam and if the news was 7 there should be a referral to ICU.
The question was if you were aware of the Lorazepam, and the NEWS score, would that have halted the transfer to AAU. You said yes.
Would that, would you still have had the opinion on the halt of the transfer when it actually occurred at 01:15 hours when actually the NEWS score was 4. Would your opinion be different based on figures at time of transfer?
CB: The question posed was immediately aware before transfer, those figures weren’t taken until after transfer
The coroner confirmed that the transfer was at 01:15 and the observations were recorded at 01:19.
CB: The transfer starts at 1am… question was about the knowledge before transfer happened, at 1 o’clock
SL: I’ll ask the question in a different way. In relation to what happened and figures available in AAU, was there any indication that transfer shouldn’t have taken place, based on the numbers at that point?
LC: <Sighs> The difficulty is those results are observations that happened after transfer, and realistically the process should be any decision or justification should be on pre-transfer observations. The immediate pre-transfer observations, the NEWS score was high.
C: Its right isn’t it, you have the 00:48 score, the transfer, then have the observations after the transfer occurs, sorry to interrupt you Ms Lyle… you should effectively re-look at observations, after which you can make a decision?
LC: Yes, would be a different situation if this set of 4 happened before transfer. I would say no cause for concern, go ahead and transfer, but you can’t have a set of observation where the NEWS score is 8 and the decision is made to transfer, without checking or escalating it to me or the clinician in the ED. That I do have an issue with.
C: Thank you
SL: That was the evidence you gave to my learned friend?
LC: Yes
SL: Just in relation to then taking into account the numbers at 01:19. I know what the process is, you’ve made it very, very clear and what you’d have preferred to happen prior to transfer. But just on the numbers at 01:19, the observations at that point, would that have actually changed anything at that point? Just based on those number at that point bearing in mind active treatment was still being undertaken at that point?
LC: I think again this is ideal situations, bearing in mind knowledge of results all happened beforehand. My preference would have been I’d have still liked to have known that.
SL: That was the process. What should have happened?
LC: On basis of several observations where NEWS score is falling in category of lower clinical concern, the actions taken by the nurse, who triaged and streamed as with other patients was routine practice I think
SL: So, if talking delays of transfer from ED to AAU, what would be your view on that? In your view were there any material, did it make a material difference that there was the time spent in A&E rather than transfer to AAU sooner?
LC: I think actually him being treated in the Emergency Department in an area where actually if I had made decision to have transfer he’d have stayed there longer, I don’t think it makes material difference he stayed in A&E as long as he did.
There was some discussion about the nurse who looked at David, Dr Chase assumes from the end of his bed and documented that he was not in respiratory distress.
Ms Lyle then asked a series of questions about whether it is possible to predict cardiac arrests. Dr Chase told the court that was why the Early Warning Score system was developed, because it has some early predictive value and that the categories contained within the calculation, such as respiratory function, cardiovascular status all have an impact on someone’s likelihood to go on to have a cardiac arrest.
SL: So the numbers at 01:19 observations taken, was there any indication at that stage that a cardiac arrest was likely?
LC: Based on that set of observations, no, not necessarily
SL: Are there scenarios whereby staff may be present, clinicians may be present with a patient who then has a cardiac arrest and there’s nothing they can do to stop it?
Dr Chase confirmed there were. She said CPR was commenced pretty quickly on David, and adrenaline was administered and after 4 cycles of CPR, approximately 8 or 9 minutes there was a return of circulation.
SL: So, at that point we’ve actually brought David back, he’s alive at that point. There are other assessments that clearly need to be carried out from a clinical perspective, but David is alive at that point?
LC: Yes
SL: Thank you, so in terms of CPR, what we hope to achieve, had that been achieved from a clinical perspective in terms of resuscitation?
LC: Clearly under ideal circumstances you’d get a return of circulation and no adverse features
SL: Yes. Which wasn’t the case?
LC: No
SL: But in terms of the CPR achieving what in blunt terms, return of circulation, that was achieved.
There were no further questions for Dr Chase. The coroner thanked her for her evidence and the sensitive way in which she answered the last set of questions.
There was a short timetabling discussion and court adjourned for lunch at 13:05.