Rafal Delezuch · Prevention of Future Deaths report

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Issued 27 Mar 2015•Leicester City and South Leicestershire

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure to apply the NICE guidance that diazepam was not recommended
    Part of recurring concern: Unsafe rapid tranquillisation processes
  2. Failure to identify and pursue appropriate quick-acting medication alternatives for rapid tranquilisation
    Part of recurring concern: Unsafe medication prescribingPart of recurring concern: Unsafe rapid tranquillisation processes
  3. Failure to recognise the dangers of prolonged prone restraint
    Part of recurring concern: Unsafe use and management of prone restraint

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. University Hospitals of Leicester NHS Trust

    Develop a shared rapid tranquillisation guideline with the Leicestershire Partnership Trust, including appropriate consideration of relevant NICE guidance.

  2. University Hospitals of Leicester NHS Trust

    Improve the accessibility of the Trust’s policy and guideline library.

  3. University Hospitals of Leicester NHS Trust

    Ensure Emergency Department clinical staff understand the Restraint Policy and dangers of prolonged prone restraint.

  4. University Hospitals of Leicester NHS Trust

    Put the shared rapid tranquillisation guideline in place in the Emergency Department.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to apply the NICE guidance that diazepam was not recommended

Wider context from the report

“(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy. (2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position (3) When it was decided that the patient was in need of rapid tranquilisation then: a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated. (4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked. ”

Is this part of a recurring concern?

Yes — Unsafe rapid tranquillisation processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to identify and pursue appropriate quick-acting medication alternatives for rapid tranquilisation

Wider context from the report

“(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy. (2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position (3) When it was decided that the patient was in need of rapid tranquilisation then: a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated. (4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing; Unsafe rapid tranquillisation processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to recognise the dangers of prolonged prone restraint

Wider context from the report

“(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy. (2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position (3) When it was decided that the patient was in need of rapid tranquilisation then: a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated. (4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked. ”

Is this part of a recurring concern?

Yes — Unsafe use and management of prone restraint.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ensure priority access to limited supplies of Lorazepam

Wider context from the report

“(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy. (2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position (3) When it was decided that the patient was in need of rapid tranquilisation then: a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated. (4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked. ”

Is this part of a recurring concern?

Yes — Unreliable access to clinically required medication during supply shortages.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of staff awareness and training in the application of the restraint policy

Wider context from the report

“(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy. (2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position (3) When it was decided that the patient was in need of rapid tranquilisation then: a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated. (4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a shared rapid tranquillisation guideline with the Leicestershire Partnership Trust, including appropriate consideration of relevant NICE guidance.

Verbatim wording from the response

“In addition, our Chief Pharmacist has met with the Leicestershire Partnership Trust to develop a shared rapid tranquillisation guideline; our Clinical Director will ensure that this guideline is in place by the end of May 2015. This Guideline will also deal with appropriate consideration of the relevant NICE Guidelines.”

Source location

2015-0024-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 27 January 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Improve the accessibility of the Trust’s policy and guideline library.

Verbatim wording from the response

“Additionally working alongside an external organisation we are undertaking work to improve the accessibility of our Trust Policy and Guidelines generally. We expect that this work to improve the accessibility of our Policy and Guideline Library and is expected to be completed by the end of June 2015.”

Source location

2015-0024-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 27 January 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Ensure Emergency Department clinical staff understand the Restraint Policy and dangers of prolonged prone restraint.

Verbatim wording from the response

“The Clinical Director and Head of Service for the Emergency Department between them have ensured that all clinical staff in the Emergency Department are aware of the Trust’s Restraint Policy and of the particular dangers of prolonged restraint in the prone position.”

Source location

2015-0024-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 27 January 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Put the shared rapid tranquillisation guideline in place in the Emergency Department.

Verbatim wording from the response

“In addition, our Chief Pharmacist has met with the Leicestershire Partnership Trust to develop a shared rapid tranquillisation guideline; our Clinical Director will ensure that this guideline is in place by the end of May 2015. This Guideline will also deal with appropriate consideration of the relevant NICE Guidelines.”

Source location

2015-0024-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 27 January 2015

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026