Coroner issues Rule 28 Regulation Report

Sarah Huntbach, assisted by Christopher Frankling, recently represented a father at an inquest investigating the circumstances and cause of death of his son.

The deceased had been under the care of the mental health services and had suffered frequent bouts of relapse, primarily caused by social and relationship circumstances.

It was during a period of relapse that he took a paracetamol overdose. At the time, he was involved with the police and it was due to the police having found him that he was taken to hospital. He had also been drinking alcohol. At A&E, the staff were informed of the deceased being found with several cans of alcohol around him and empty packets of paracetamol. The deceased gave an indication of when he had taken the drugs and so with a blood test having been done, the information was able to be entered into the Toxbase system. The blood result, when factored in with the length of time elapsed since overdose, resulted in the plasma concentration falling below the treatment threshold. He was discharged back to the care of the police in custody. However, less than 24 hours later he reported again to the A&E department with a fast heart rate, pain in the lower abdomen and he had vomited. On this occasion a blood test was not done and his symptoms were attributed to alcohol withdrawal and he was discharged. He again returned 24 hours later, but this time was too ill for treatment. He subsequently died in hospital and at the inquest the medical cause of death was found to be paracetamol-induced liver injury.

At the inquest, the Toxbase guidelines for paracetamol overdose were considered and it was identified that guidelines stated a risk of severe liver toxicity developing in a few patients with a plasma paracetamol level that initially falls below the threshold for treatment. It was also identified at the inquest that the Toxbase guidelines do not expressly state whether they apply only to an initial attendance and as such would not be necessary for consideration on reattendance.

Following the deceased’s death, the NHS Trust undertook a ‘root cause analysis’. This was led by a Consultant Hepatologist and the conclusion was that if a blood test had been done upon arriving at A&E for the second time, it was likely to have been abnormal and treatment would have been offered. At the inquest, evidence was heard from both a registrar and consultant from the A&E department and both stated that, whilst they acknowledged the Toxbase guidelines identified the risk of severe toxicity development, they could not explain why the guidelines should not be considered and applied on representation to a hospital.

The Coroner was so concerned by this that she has issued a Rule 28 Regulation Report to the providers of the Toxbase guidelines, the National Poisons Information Service (NPIS). This imposes a duty on the NPIS to take action to prevent future deaths – the suggested action being to review the existing Toxbase guidance and how it is to be used with respect to representation at a hospital for paracetamol overdose.

It is not uncommon for a coroner to issue such a Regulation 28 report to prevent future deaths where there is concern that existing practices should be reviewed / altered. The effect of this is to continue to identify and develop changing practice to ensure lessons are learned and steps are taken to minimise the risk of death.

For more information

For more information on clinical negligence claims, or if you require support through an inquest, please contact Sarah Huntbach.

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