CHAND ALI · Prevention of Future Deaths report

I commenced an investigation into the death of Chand Ali on 14th December 2017. The investigation concluded at the end of the inquest on 28th February 2019.

The Deceased was a 78 year old man who suffered severe, end-stage, heart failure and was diabetic. On the 7th July 2017 he attended the outpatient heart failure clinic at St Bartholomew’s Hospital for review and was found to have developed significant fluid overload and decompensated heart failure and, in consequence, at about 3pm he was admitted to Ward 6D of the hospital. Upon admission and over the following hours the Deceased was alert and responsive. At about 5.20 pm he was given an intra-venous dose of cyclizine, an antiemetic which, according to the British National Formula, must be used with caution for patients suffering severe heart failure. At about 6.45 pm he was found to have a low blood glucose level and this was treated with the provision juice and food, which he drank and ate, and the administration of glucogel. Subsequently, at about 7.20 pm, he was found to be unresponsive and his death was pronounced at 7.50 pm. On the balance of probabilities the Deceased’s death resulted from his decompensated heart failure. The possibility that the dose of cyclizine contributed to the heart failure and death cannot be ruled out but, on the evidence available, could not be said to be probable.

The medical cause of death was :

Ia Decompensated Heart Failure
Ib Ischaemic Heart Disease
II Chronic Renal Failure, Diabetes

My conclusion as to the death was : Natural Causes

As stated above, cyclizine is an antiemetic which, according to the British National Formula, must be used with caution for patients suffering severe heart failure, especially if it is administered intra-venously.

The evidence revealed that cyclizine is administered to heart failure patients at St. Bartholomew’s Hospital, including those suffering severe heart failure, as the routine or standard antiemetic and without consideration of its likely effect on the individual patient in question. There is no system in place in the hospital requiring the prescriber to balance any risk to the patient arising from the use of cyclizine against the patient’s clinical need for it, in order to justify its prescription.

Further, whilst it was said that the Hospital was not aware of any pattern or trend of deaths following the administration of cyclizine, it was accepted that the actual incidence of such deaths was not, in fact, known. It was accepted that monitoring and analysis of all deaths following the recent use of cyclizine would be needed in order to establish a reliable picture.

It was also apparent from the evidence that there had been no comprehensive review of other available antiemetics in order to explore whether there exists and effective alternative antiemetic which is not subject to a caution in the British National Formula as to its use.