Paul David Ryley · Prevention of Future Deaths report

On 15/06/2018 I commenced an investigation into the death of Paul David Ryley. The investigation concluded at the end of an inquest on 11th September 2018. The conclusion of the inquest was of an Alcohol and drug related death.

The Deceased died at the Birmingham Heartlands Hospital at 11:36 on the 14th April 2018 as a result of the effects of a paracetamol overdose on the 10th April 2018. He had attended hospital on the 10th April at which time he showed no clinical symptoms of paracetamol toxicity and his plasma concentration was below the treatment threshold. However, he presented again on the 11th April with persistent tachycardia, lower stomach pain, episodes of nausea and vomiting and visual hallucinations, routine blood tests were not undertaken and his symptoms were attributed to alcohol withdrawal despite a known risk that severe liver toxicity can develop in a few patients with a plasma paracetamol level that appears below the threshold. It is likely that routine blood test results would have been abnormal resulting in diagnosis and treatment which would have given a 50% chance of success. By the time he was admitted on the 12th April the deceased was too ill for treatment. The Deceased’s intention when he overdosed on the 10th April cannot be identified on a balance of probabilities..

Following a post mortem the medical cause of death was determined to be:
1a) PARACETAMOL INDUCED LIVER INJURY

1. The Toxbase Guidelines for Paracetamol overdose (which comprise of a general guidance sheet and then several sheets specific to the period since ingestion) were considered and it was identified that they do not expressly state whether or not they apply only to an initial attendance and do not set out any steps to be followed when a patient re-presents within a short time of an initial attendance for a Paracetamol overdose.

2. Evidence was heard from an ED Registrar, ED Consultant and the Consultant Hepatologist that lead the Trust’s root cause analysis investigation that the guidelines are commonly understood by emergency department practitioners within this Trust and elsewhere to be applicable only to the patient’s initial attendance and are therefore not considered when a patient re-attends even when that re-attendance is within days (in this case within 24 hours) of the initial attendance. Evidence from the experienced ED Consultant was that this is what he had understood from local and national training.

3. The evidence before the court was that it is, or ought to be, known that despite a plasma paracetamol level below the therapeutic threshold patients can go on to suffer liver toxicity following a paracetamol overdose and this is clearly stated within the Toxbase guidance.

4. In this case the clinicians did not refer to the Toxbase guidance when the Deceased represented other than to check that on his initial presentation his plasma paracetamol level had been below the therapeutic level (which it had been).

5. The evidence of a Consultant Hepatologist at the inquest was that he could not foresee any real risk in practice from following the guidance within the applicable Toxbase sheet based on time since ingestion even on a representation and to do so would in some cases result in treatment and avoid death.

6. There is therefore a risk that patients are not being given treatment that would increase their chances of survival because clinicians do not have clear guidance on what to do when a patient re-presents and do not regard the existing guidance as applicable.