Nisren Abdul-Karim · Prevention of Future Deaths report

On 5th August 2024 I commenced an investigation into the death of Nisren ABDUL-KARIM. The investigation concluded on the 19th August 2024 and the conclusion was one of Narrative: Died from natural causes contributed to by the complications of an accidental fall sustained whilst unobserved as an inpatient. The medical cause of death was 1a) Hospital acquired pneumonia 1b) Frailty 1c) End stage neurodegenerative condition 1d) Fall (1st Nov) requiring surgery for hip fracture (2nd Nov), Behcet's disease.

Nisren Abdul-Karim had a number of underlying health conditions including Behcet's disease. In Autumn 2023 she began to hallucinate. She was admitted again to Wythenshawe Hospital on 21st October 2023. She was a high falls risk. Whilst an inpatient and unsupervised she had a fall. She should not have been unobserved. She was operated on for a fractured hip sustained in the fall. She was transferred to Trafford General Hospital for rehabilitation on 10th November. The transfer meant that access to neurology was more difficult because the service provided by neurologists was not available at Trafford General Hospital. She continued to deteriorate at Trafford General Hospital. Further advice was sought via patient pass from the neurology team at Salford Royal Hospital. Review of the scans previously undertaken concluded that she had irreversible neurodegenerative disease. She continued to deteriorate and died at Trafford General Hospital on 5th January 2024.

The evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass. This meant accessing the notes required recognising that patient pass needed to be accessed.
In addition the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology. As a consequence delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all contact with neurology is telephone or patient pass as there is no face to face neurology service.