Prevention of Future Deaths reports · 2014

Leslie Harding

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 report8 Apr 2014
Reference2014-0169
DeceasedLeslie Harding
CoronerAndrew Cox
Coroner areaPlymouth, Torbay & South Devon
CategoryCommunity health care and emergency services related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from Oakside Surgery (PDF)
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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