Saif Mubeen Hussain · Prevention of Future Deaths report

I conducted an inquest into the death of Saif Mubeen Hussain on 19th November 2021.

I recorded a conclusion of suicide

The family asked me to refer to the deceased as Saif during the inquest. I will respect that wish in this report.

Saif Hussain was born on 22nd January 1998. He had no recorded mental health history. Tragically, for reasons unknown to family, he ████████ in Bracknell, Berkshire on 3rd June 2021 and ████████. He was admitted to the John Radcliffe hospital later that day, but died there on 10th June 2021. His cause of death was polytrauma.

For the absence of doubt, the issues raised below in relation to the hospital management are unlikely to have played a part in causing Saif’s death, but I do consider that there is a risk of future deaths for other patients unless these issues are addressed.

Saif was managed in the AICU from 4th to 7th June. On the 7th June, he was transferred from AICU to NICU. He had various infusions running, including a Heparin infusion. At the time of transfer, he was prescribed a dose rate of 1.4 ml/hour. Saif was also on a phosphate infusion, prescribed at 8.3 ml/hour.

Whilst the prescribed doses remained the same, he was in fact administered a dose almost 8 times higher than that, namely 8.3 ml/hour. It seems likely that the rate prescribed for the phosphate infusion was mistakenly applied to Heparin.

This matter has been investigated, and the trust has produced an excellent report. The evidence heard at the inquest, and within that report, show that:

1. Nurses working in a NICU do not routinely use anticoagulant medication. The nurses who started the wrong Heparin rate were not familiar with usual dosage rates.

2. There were several nurses involved at that point, perhaps with a lack of ownership in terms of accuracy of the dose rate. This was also not double checked.

3. The Guardrails system (which would have prevented such an exceptionally high dose being administered) was switched off in order to allow the nurse/s to administer a rate of 8.3 ml/hour.

4. The systems in place at the time allow for the prescription rate and administration rate to be markedly different without that being flagged up.

5. Crucially, the hospital uses different computer systems in different parts of the hospital, to record patient records. The risks would clearly be much reduced, particularly for transfers within the hospital, by all departments being on the same system.

We heard in evidence that the trust has always planned to consider amalgamation of the different IT systems. It is not for me to say which system they should or should not adopt. I accept that there may be advantages to the current system that were not explored during the inquest. I do however consider that there should be some focus on these issues within the trust, and an urgent review should be conducted.

The trust should consider :

1. A single system for record keeping and monitoring.

2. How the system could incorporate appropriate limits on the administration of certain drugs within that system.

3. Whether software like Guardrails should be implemented more widely, and consideration given to when and how it is possible to override this, and how that should then be documented.

4. Adopting a system of flagging up where prescription and administration of drugs is different.