Mr. Isaac BAHAR · Prevention of Future Deaths report

On 11th May 2015 I commenced an investigation into the death of Isaac Silas BAHAR. The investigation concluded at the end of the Inquest on 14th May 2015. The Narrative conclusion of the Jury Inquest was:-

Mr. Isaac BAHAR was a vulnerable man living at Hyman Fine House. He had a diagnosis of Bi-polar affective disorder. His mental health deteriorated requiring voluntary admission to Mill View Hospital.

On the 10th of November, during the early hours Mr. Isaac BAHAR suffered an unwitnessed fall. At approximately 9:00am on the 10th November emergency services were called and Mr. BAHAR was admitted to The Royal Sussex County Hospital, where following examination it was determined that he had sustained four fractured ribs and a traumatic pneumothorax for which he was treated.

His medical records stated that he had stage four chronic kidney disease. As part of his treatment he was prescribed codeine by the locum doctors on duty at that time, which was in contravention of the national and local guidelines. The prescription was reviewed by the pharmacist the next day and was withdrawn. Mr. BAHAR appeared to stabilise but suddenly deteriorated on the 13th of November. He was attended by the Medical Emergency Team at which stage the decision was taken to administer Naloxone to counter the toxic effects of codeine to which he partially responded. However, his condition continued to deteriorate rapidly, resulting in his death.
It was later discovered by the pathologist that Mr. BAHAR had chronic obstructive pulmonary disease, which was deemed to be a contributory factor in his death.

See Record of Inquest

Mr. Bahar was admitted to the Royal Sussex County Hospital on 10th November 2014 with pneumothorax due to fractured ribs. He was treated urgently and appropriately until his analgesia.

He was a man with known Stage 4 Chronic Kidney Disease, yet in breach of the hospital’s own policy and in breach of national guidance he was prescribed and given four doses of Codeine over 18 hours. Although this was stopped by the ward Pharmacist as soon as she was able to review his drug chart, Mr. Bahar collapsed with severe opiate/opioid toxicity 30 hours later and died just under three hours after the collapse. The Jury at his Inquest found this error to be one of the causes of his death

The Codeine was directed by a locum surgical consultant and the fatal error was compounded when a locum junior doctor wrote up the Codeine in Mr. Bahar’s drug chart.

Their locum status must be relevant and if the Trust employs locum staff they must satisfy themselves that those staff are aware of such guidance particularly in such a common scenario (elderly patient with Chronic Kidney Disease needing analgesia).

The Trust is responsible for ensuring their patients are in safe hands. Senior nurses should also be aware of such common pitfalls. They would then be in a position when caring for their patients to pick up anomalies.

This is a serious failing and must be urgently addressed.