James Robert Quinton · Prevention of Future Deaths report

On 25/03/2017 I commenced an investigation into the death of James Robert Quinton, 42 . The investigation concluded at the end of the inquest on 30 January 2018. The conclusion of the inquest was a Narrative conclusion: James Robert Quinton collapsed on 14 March 2017 due to a combination of a ruptured spleen and methadone and heroin ingestion. Mr Quinton failed to respond to extensive resuscitation and supportive measures and he died in the Doncaster Royal Infirmary later that day. The cause of death was 1a. Splenic rupture and combined morphine and methadone toxicity 2. Rivaroxaban therapy

James Quinton had a known history of chronic drug and alcohol abuse. His partner ████████ had been in a relationship with him for 12 years and has no knowledge of him having ever had an employment. He had a medical history of alcoholic liver disease, intravenous drug misuse, hepatitis C, epilepsy, previous DVT, or rivaroxaban, schizophrenia. He was admitted to DRI A&E at 02:30 hrs with a preexisting history of 1 week vomiting blood, 1 day abdominal pain. He had been found unresponsive on the bathroom floor collapsed. On admission he was unresponsive - Investigations commenced -Bloods were taken - INR 3 - given vitamin K to reverse. Acidotic PH6.8, lactate greater than 20. 03:15 hrs cardiac arrest - arrest call - ALS - adrenaline, noradrenaline given. Femoral line put in place, sodium bicarbonate and glucose given, ROSC GCS low - pupils remained fixed and dilated. CT abdomen results - query splenic bleed. He was transferred to ICU - reviewed and discussions held with NOK. Decision due to significant Co-morbidities and poor status it was the opinion of the physicians that he would gain no benefit from any surgical intervention. Active treatment was withdrawn and he died on 15/03 at 14:26 hrs. I have spoken to Kelly Coates (partner) and she informs that the last time the deceased used illicit drugs was on the morning of Monday 13th March (heroin). She states that over the previous 7 days he had been unwell periodically vomiting.

(1) During the course of the evidence it became clear that the poor quality nursing notes and the lack of information of the observation chart made it difficult for the reviewing Consultants to get a clear picture of events that had been occurring. Clearly poor record keeping has significant implications for patients.

(2) Furthermore, during the course of the resuscitation a decision was made for Mr Quinton to be given 4 mgs of Noradrenaline. This was to be given as an infusion. Unfortunately, this was actually given as a 4 mg iv bolus. Although the records suggest this did not have a detrimental effect on Mr Quinton (his blood pressure had been exceptionally low) this clearly could be highly significant for other patients. It also raises the question of other patients being given either the wrong drug or the wrong amount of drug or the wrong method of administration when the procedure for drugs to be prescribed in this scenario is on a verbal basis only. It would seem sensible to have some checking procedure by the person administering the drugs checking with the person who had prescribed it to make sure their understanding is correct. From the evidence I heard it seems there are no such procedures in place.