Mohammed Abdus Salem · Prevention of Future Deaths report

On 9 April 2021 an investigation into the death of Mohammed Abdus Salem was commenced. The investigation concluded at the end of the inquest on 14 October 2021, I recorded a conclusion of death by natural causes.

The deceased was diagnosed with chronic myelomonocytic leukaemia (CML) in October 2020. This illness was managed conservatively and the deceased required and received regular blood transfusions and oral chemotherapy to maintain control of his white cell count.

The deceased’s health remained stable until March 2021 when his condition deteriorated significantly. It was noted that the deceased’s CML had rapidly progressed. On 29 March 2021, the deceased was admitted to the Royal Oldham Hospital for inpatient treatment. He was treated with intravenous fluids and antibiotics and his oral chemotherapy medication dose was increased.

By 31 March 2021 the deceased’s condition had further deteriorated. He was commenced on Rasburicase to reduce the risk of him developing tumour lysis syndrome. While it was intended that the deceased receive a further dose of Rasburicase on 1 April 2021 this drug was not given despite high urate levels being detected. This was medication that could either be administered as a single dose or as part of a longer course. I heard evidence that the prescribing doctor intended that the Deceased receive more than one dose however this was not specified in the notes or in the prescription. The clinicians who reviewed the deceased on 1 April 2021 assumed that only one dose was required.

During the late evening of 1 April 2021, the deceased was discovered unresponsive. His death was confirmed shortly afterwards on 2 April 2021.

It is more likely than not that had a further dose of Rasburicase been administered to the Deceased on 1 April, his life would have been prolonged by up to 48 hours.

1. The Root Cause Analysis (RCA) undertaken by the Northern Care Alliance identified that a dose of Rasburicase had not been administered on 1 April 2021 however it did not consider any of the factors that gave rise to that omission or its consequences. My concern is that the RCA fell short of the required standard of rigour which leaves residual questions as to organisational governance standards and learning from death.