Michael George · Prevention of Future Deaths report

On 9th December 2011, I opened an inquest into the death of:
Michael George, who died on 7th December 2011, at 02.40 a.m. in King’s College Hospital, Case Ref: 03102-2011.

It was concluded before a jury on 12th June 2015.
The court found that the medical cause of death was
1a Multi-organ failure
1b Hyperosmolar hyperglycaemic state, in schizophrenic treated with Olanzapine.

The narrative conclusion included these matters in the record:

a) The Maudsley Hospital failed to address the risk of Mr George developing diabetes from the long term use of Olanzapine and did not check his urine or blood sugar prior to 06/12/11.

b) At 09.30 on 06/12/11 Mr George complained of being weak, tired, having blurred vision and making frequent trips to the lavatory and asked to see a doctor. At a case review meeting held at 11.00 a.m. on 06/11/12 the results of a urine test, which showed the presence of blood and glucose, a physician was not consulted, leading to an inadequate care plan....

c) At 18.30 when the laboratory .. phoned through the blood glucose results... the precise measurement of 53.7 mmol/l was misunderstood by staff, who did not appreciate that [his] condition was life threatening. As a result.... decisions regarding .... transfer to A&E had an insufficient level of urgency. [NB: There was no entry of 53.7 in records]

d) From 18.30 once these glucose results were received, the Maudsley Hospital attempted to transfer Mr George to A&E. However the time delay between 18.30 and 21.20, when he eventually arrived at A&E had a significant impact on his chances of survival because it delayed the administration of sufficient levels of fluid to aid his rehydration.

e) The referral information from the Maudsley did not contain critical information about Mr George’s background and current condition to enable A&E to appreciate the urgency of his condition and the difficulty of managing a patient who was refusing treatment.

It should be added that it was reported that for a large part, but not all of his hospital admission, he had capacity and exercised it to refuse investigations and transfer.

Expert evidence was heard that:

(1) The management spokesperson on the Action Plan at the inquest was unaware that the Trust had received these two court Regulation 28 reports, suggesting that senior management attached insufficient importance to them and the issue of physical health care of mentally ill patients.

(2) Although there was now systematic recording of urine and blood glucose of patients on antipsychotics on the wards, the audit conducted and presented in court showed a number of patients who had refused these tests, but not demonstrated whether in subsequent weeks testing was conducted or whether these same patients, like Mr George, never had their glucose measured, noting that urine measurement was non invasive, and had an appropriate care plan to address these risks.

(3) The Trust response to 2654-11 in September 2014 was that a research bid was being mounted and discussions held with commissioners and Kings College Hospital (KCH). Progress on this was not provided to the court and there had apparently not been action to reduce risks of deaths by ensuring there were domiciliary visits from consultant physicians at KCH (which is across the road from the Maudsley) to mental health wards, as reported to the Trust in 2014. The need to implement such a service was again reiterated by a different expert in this inquest. It is inferred from the expert opinion that failure to do so would mean that patients in SLAM in-patient units would be more at risk than those mental health patients in a district general hospital.

(4) Whilst there had been individual learning and changes in training and note keeping and recording, it was unclear whether, in the absence of consultant physician advice, that the serious untoward incident investigation conclusion on urgent transfer would be heeded. It advised that there should have been immediate action to call an ambulance to effect transfer, despite lack of consent, when the blood results were known.