Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0197, written 1 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 May 2014 |
|---|---|
| Reference | 2014-0197 |
| Deceased | Elizabeth Cooper |
| Coroner | Philip Sharp |
| Coroner area | Cumbria (South & East) |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 BEING SENT TO:
1.
2.
3. The Chief Coroner
General Medical Council
N.I.C.E.
1 CORONER
I am Philip Alan Sharp, Assistant Coroner, for the coroner area of South and East Cumbria
2
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.
3
INVESTIGATION and INQUEST
On the 16th September 2013 I commenced an investigation into the death of Elizabeth Jayne
Cooper who was born on the 2nd Nov 1980. The investigation concluded at the end of the inquest
on 23rd April 2014. The conclusion of the inquest was that Elizabeth died of 1a Pulmonary
Thromboembolism 1b Deep Vein Thrombosis right lower limb 1c Hypercoagulable state due to
Factor V Leiden mutation. I gave a conclusion of natural causes.
4
CIRCUMSTANCES OF THE DEATH
Elizabeth had been diagnosed with the genetic condition referred to in 1c above in 2011. This
followed a diagnosis of a DVT and possible pulmonary embolism. Elizabeth was clinically obese
and suffered from diabetes. She was thereafter given conflicting advice on the precautions she
should take if she travelled by air. One specialist advised her to take anticoagulant prophylaxes but
her GP did not consider this to be necessary. She died immediately following a holiday to Tenerife
involving air travel. No causal connection was made in the inquest between the flights and her
death but it became clear from the evidence that although she was aware of the risks created by
the condition and other risk factors she seemed not to be aware of the consequences of taking any
of those risks of which flying was one. Her actions on becoming ill on holiday support this conclusion.
The literature from her specialist did not give any warnings in this regard. The guidelines produced
to the inquest highlight the statistical increase of risks but not the consequences of an untreated
DVT. Her sister who gave evidence, although not carrying the genetic condition, had previously
suffered a DVT and was similarly not aware of the fatal consequences of an untreated DVT.
Further her family had not been made aware of the option to be tested for the genetic condition to
enable them to properly consider their own health requirements.
5
CORONER'S CONCERNS
During the course of the inquest the above 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.
1
The MATTERS OF CONCERN are as follows:-
(1) Advice on precautions to be taken for those persons with the genetic condition is unclear
especially concerning air and long distance travel.
(2) There seems no clear pathway for information concerning the condition to be passed to
members of the family of the patient for them to assess their own position.
(3) No information leaflet
(a) was available to Elizabeth concerning the fatal consequences of not seeking
medical assistance;
(b) was available to be given to members of Elizabeth’s family to inform them of the
risks involved in Factor V Leiden Mutation and the options open to them.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
Organisation has the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
26th June 2014. I, the Assistant Coroner, may extend the period.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
(Elizabeth’s GP). I have also sent it to The British Society of
(Sister)
Physicians who may find it useful or of interest.
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 of the publication of your response by the Chief Coroner.
9
[DATE] [SIGNED BY CORONER]
2
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