Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0169, written 8 Apr 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Apr 2014 |
|---|---|
| Reference | 2014-0169 |
| Deceased | Leslie Harding |
| Coroner | Andrew Cox |
| Coroner area | Plymouth, Torbay & South Devon |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS This report is made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Recipients This report is being sent to: , Oak side Surgery, Honicknowle Green Medical Centre, Guy Miles Way, Honicknowle, Plymouth PL5 3PY (wife) (daughter) (daughter) (daughter) Coroner I am ANDREW JAMES COX, Assistant Coroner for the area of Plymouth, Torbay and South Devon. Coroner’s legal powers I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Investigation and Inquest On 30 September 2013 I commenced an investigation into the death of Leslie Edmund Harding (Lez), aged 57. The investigation concluded at the end of the inquest on 2 April 2014. The cause of death was found, at post mortem, to be: 1a 1b 2 Pulmonary Artery Embolism Deep Vein Thrombosis of Left Calf Pulmonary Oedema 1 The conclusion of the inquest was that Lez died from Natural Causes Circumstances of death Lez had a complicated past medical history. He was diagnosed with Multiple Sclerosis in 2002. He had also suffered with recurrent, periodic Pulmonary Emboli from 1997. Lez had been a patient at your practice for over 20 years. Between 2002 and 2007, however, following a change of address, he was registered with another GP Practice. At Inquest, I heard evidence that he suffered two P.E’s in 2003 and a further P.E. in 2005. Lex re-registered with your Practice circa 2007. He did not appear to have undergone a new patient assessment. It was not possible at Inquest to establish whether this was due either to the Surgery failing to contact Lez or Lez declining to attend for such an assessment. had referred Lez to the Haematology By September 2011, however, Department at Derriford Hospital. A report from a Clinician dated 13 September 2011 was read out at Inquest. It was noted that Lez had not had a clot in the previous four years and that Clexane was a suitable form of treatment for him given his difficulties in stabilising on Warfarin. At Inquest, gave evidence that Lez was poorly compliant with the Clexane regime. It was noted that in November 2011 and January and March 2012 the Surgery did not prescribe Clexane to him. It was further noted that between May 2012 and July 2013, no prescriptions for Clexane were written by the Surgery although a month’s supply was believed to have been provided by Derriford. The family disputed the extent to which Lez was non-compliant with the treatment regime. said that Lez had been advised by a doctor at Derriford that he no longer needed to take Clexane. On 18 September 2013, was requested to see Lez at home. This followed his earlier admission into the Acute GP Service in Derriford on the 16 September where, after assessment, he self-discharged. gave evidence at Inquest that he found Lez to be angry and in discomfort. Lez was fed up that nothing was being done and he was complaining of pain in his chest. told me that he wanted to re-admit Lez who was resistant to this suggestion. also said that he wished to consider whether Lez would be suitable for treatment with a new form of anti-coagulation, namely, Riveroxyban. Before prescribing this, said that he wished to discuss to whom a referral had been made in August. He the option with also wanted to check Lez’s kidney function. 2 told me that he attempted to telephone on his return to the Surgery but was unable to contact him. He intended to follow up this approach but did not do so. At Inquest, said that it slipped his mind for which he apologised. took no steps to treat Lez after seeing him until his collapse and death on the 28 September 2013. I heard no evidence at Inquest as to whether, if anti-coagulation treatment had been started after the appointment on the 18 September Lez’s death 10 days later could have been avoided. Coroner’s concerns During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The matters of concern are as follows. 1. took no action during the period from 18 – 28 September 2013. Patients with a suspected life-threatening condition (Pulmonary Embolus) must be promptly treated. The system for ensuring that the treatment is provided must be robust. That is particularly the case where it is already known that the patient suffers from an underlying condition that makes him prone to the particular life-threatening event. 2. Your practice will have a number of other patients in receipt of anti- coagulation treatment following recurrent Pulmonary Embolii. Given the omission that appears to have occurred here, you need to ensure that no other omissions have happened with any of the other patients 3. At Inquest, I gained the impression that Lez was felt to be non- compliant with his anti-coagulation regime. It was plain from the prescription history that there were repeated gaps in the provision of medication that Lez required. There seemed, however, in my view, to have been little effort given to addressing the reasons why, or indeed if, Lez actually was non-compliant with his medication. By way of illustration, I was not shown a letter from the Surgery to Lez bringing to his attention that he had failed to collect his monthly supply of Clexane and warning him of the risks of failing to maintain the treatment regime. I heard evidence at Inquest that Lez could be an awkward patient. In my view, of itself, that is insufficient reason not to make every reasonable effort to ensure that a patient complies with an identified need for lifelong anti-coagulation. 4. I was advised that this death had not yet been reviewed in a significant events meeting. In my view, that should have taken place forthwith after Lez’s death. You may wish to convene a significant events 3 Action should be taken In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. Your response You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 June 2014. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. Copies and publication I have sent a copy of my report to the Chief Coroner and to the Interested Persons listed above. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. A J COX Assistant Coroner Plymouth Torbay and South Devon Area Date 8 April 2014 4
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Oakside Surgery Dr James R Butler Honicknowle Green Medical Centre Dr Nick Allison Guy Miles Way Dr Duncan Parker Honicknowle Plymouth PL5 3PY 22 August 2014 F.A.O AJ Cox Assistant Coroner Plymouth, Torbay and South Devon 3 The Crescent Plymouth PL1 3AB Dear AJ Cox Re: Mr Lez Harding 27/08/1956 492 Kings Tamerton Road Kings Tamerton Plymouth PL5 2BS NHS: 452 703 0035 Thank you for your letter dated 17® of July. I have now had the chance to read through your report and the concerns you raised. The paragraphs I have numbered below correspond to those in your Regulation 28 Report with your letter dated 2"? July 2014 on page 3. The relevant points are detailed below: 1) It was noted ino took no action during the period from the 18° to 20" September 2013 for which he once again expressed profound regret. As an individual he has decided to adopt a system used by other members of Staff within the Practice of writing notes to himself using a computer appointment system as well as a ring bound note book. I did note that Mr Harding was judged to have mental capacity and that he appeared to have made an informed decision in the days leading up to the 18" September 2013 on more than one occasion not to have been admitted to hospital and received what I can consider to be the appropriate treatment. He appears to have made this decision in the knowledge that the outcome could have been fatal. While this is clearly not an outcome that anyone would have wished for, I did note that it is important that our therapeutic relationship remains advisory and that patients with the appropriate mental capacity are allowed to make decisions which may lead too later harm and might be regarded as decision which do not conform with best medical practice. I also feel that it would have been inappropriate of: have treated Mr Harding as if he had a pulmonary embolism within the community without appropriately investigating it with investigations which were only available within a hospital setting. If he had done so, this would have raised the possibility of over anti-coagulating him, which could have had equally serious consequences. The only alternative medications available for this (and the one which the medical — ie considering) are both unable to be closely monitored and are also irreversible in the event of catastrophic haemorrhage. 2) Having reviewed this case, I am undertaking an audit of all people receiving treatment for pulmonary emboli whether acute or recurrent to ensure that no similar omissions have occurred. 3) As a result of this situation, I have reviewed the advice given to people when they first begin anti-coagulation and as a practice we are in the process of composing a letter informing people of the risks of non-concordance with medication. We have also decided to extend this review to patients receiving low molecular rate heparin and novel oral anti-coagulants. 4) lam relatively new to the Practice but my colleagues were able to produce evidence that the situation had been reviewed formally on a number of occasions and now we have your further report I have scheduled a further discussion of the entire case at the next significant event analysis meeting in the Practice which will take place in September 2014. If you have any further. questions then please do not hesitate to contact me. Yours sincerely
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