Nuliyati BUSINJE · Prevention of Future Deaths report

On 21 April 2017 I commenced an investigation into the death of Nuliyati BUSINJE aged 52. The investigation concluded at the end of the inquest on 18 April 2024. The conclusion of the inquest was that:

Narrative Conclusion - Nuliyati Businje died as a result of a massive pulmonary thromboembolism (clot) for which there were a number of factors:
- Fluid monitoring was inadequate and the lack of a plan to address this probably caused or contributed to death.
- Nuliyati's lack of compliance for diabetes treatment and absence of a plan to address this possibly caused or contributed to her death.
- The plan and management from 7 April onwards when Nuliyati's blood sugars were high and uncontrolled with the use of insulin, and when significant changes in her vital signs were seen, and a lack of referral, probably caused or contributed to her death.

Ms Businje was an inpatient on a psychiatric unit, sectioned under the Mental Health Act. On admission, her VTE risk was assessed and, on the basis that her mobility was not significantly reduced from her baseline, she was deemed to be not at risk and no VTE prophylaxis was given. During her admission she was accepting only limited diet and fluids, and was refusing medication for her diabetes. 8 days into her admission, her physical observations became abnormal (NEWS 7 which included a blood pressure which could not be obtained) and her blood sugar levels were high (20+mmols). The on call doctor was called, who repeated her observations and found these to be normal (NEWS 0). Insulin was given but that evening her blood sugar continued to rise, resulting in an increased dose in insulin. On day 10 of her admission, her blood sugar reading was over 33.1mmols and she subsequently suffered a cardiac arrest. The post mortem examination found a massive pulmonary embolus, due to deep venous thrombosis.

Expert evidence was obtained from a consultant physician and he gave oral evidence in court. He explained that Ms Businje had a number of risk factors for DVT, including dehydration, her age and obesity. In his view, the risk assessment should not have stopped once significantly reduced mobility was ruled out, as her other risk factors would necessitate the need for VTE prophylaxis. He was surprised when it was pointed out to him that the Department of Health VTE risk assessment tool in place then (2017) and still in place now suggests there is no need for further assessment. A consultant psychiatrist on behalf of the Trust gave evidence that there is a growing body of research which indicates that psychiatric patients on a ward are also at higher risk of DVT and as such they have amended their local assessment tool to consider other factors over and above mobility.

1. Despite evidence to suggest that mobility is not the ultimate deciding factor of risk of DVT, the risk assessment tool as currently drafted and relied upon by clinicians would suggest that there is no further need for assessment. This raises a risk of future deaths for those patients such as Ms Businje who were at risk of VTE, or those with cancer for example, but who do not have significantly reduced mobility and would therefore fall outside of the risk assessment.
2. Based on the evidence I heard, patients on a psychiatric unit are at increased risk of DVT but this is not factored into the risk assessment, nor the NICE guidance. The latter guidance has a specific section for psychiatric patients but does not provide any specific information as to risk and directs the reader to the same Department of Health risk assessment tool.
3. Based on the evidence of the expert physician, a common presentation of a clot can be a derangement in observations such as respiratory rate and heart rate, but these can normalise as the clot furthers on and the blockage eases. I am concerned that this does not appear to be widely known, is not part of training at least in the Trust in this case due to the lack of awareness, and I am told is not something which is taught nationally. There is a risk that a clinician without this knowledge would, as in this case, be reassured by the improving observations and the clot, and risk of a further more serious clot, would be overlooked.