Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0226, written 9 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 | 9 May 2014 |
|---|---|
| Reference | 2014-0226 |
| Deceased | Linda Fisher |
| Coroner | Alan Wilson |
| Coroner area | Blackpool & Fylde |
| Category | Hospital Death (Clinical Procedures and medical management) 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive, Blackpool Teaching Hospital NHS Foundation Trust 1 CORONER I am Alan Wilson, Senior Coroner, for the area of Blackpool & Fylde 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 24th August 2013 I commenced an investigation into the death of Linda Yvonne Fisher, born 16.04.52. The investigation concluded at the end of the inquest on 1st May 2014. The inquest determined that the medical cause of death was Ia Pulmonary Embolism 1b Deep Vein Thrombosis of Left Leg Veins The conclusion of the Coroner as to death was a Narrative Conclusion, as follows: Linda Yvonne Fisher was admitted to hospital on 8th October 2013 complaining of knee pain. An examination undertaken at approximately 22.34 hours on 12th October 2013 suggested that it would be prudent to start treatment for a suspected deep vein thrombosis and a Doppler scan was requested. Dalteparin medication was increased to 15000 units. The Doppler scan was requested on 14th October 2013, performed on 15th October 203 and it confirmed the presence of a left proximal deep vein thrombosis, and Dalteparin medication was increased to 18000 units. Despite ongoing treatment the deceased was found collapsed at approximately 10.40 hours on 17th October 2013 and died. A subsequent post mortem examination undertaken on 21st October 2013 confirmed she had suffered a pulmonary embolism which proved fatal. 4 CIRCUMSTANCES OF THE DEATH See the contents of section 3 above 5 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 1. The inquest heard evidence that patients may be admitted to hospital who, once medically assessed, may require medication the dosage of which may be determined by the weight of that patient. On occasion such a patient may not be able to be weighed in order to determine their weight, perhaps for example due to a leg injury that prevents the patient bearing their own weight for long enough to allow medical staff to weigh them. In such circumstances, a Doctor placed reliance upon the Deceased’s own verbal assessment of her own weight and used this information to decide upon the medication dosage. Although I was informed that the Trust is aware of this issue and have considered one method of resolving it [which I understand is not to be implemented], I remain concerned that patients may be prescribed medications at a dosage which is inaccurately determined due to the fact that a patient has incorrectly assessed their own weight, and if patients do not receive the correct dosage future deaths may result. 2. The inquest also heard evidence that other members of the Deceased’s family had suffered from a similar condition. There were no records to suggest that this relevant information had been obtained by medical staff following her admission, and therefore nor had it been communicated effectively to other staff who may in due course have had involvement in her care. I am concerned that if such information is not obtained appropriately from patients and is not communicated effectively to other hospital staff then decisions pertaining to clinical care may be made erroneously and future deaths may result. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have 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 . 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 following Interested Persons The family of Linda Yvonne Fisher The Coroners Society 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. 8 9 2 Alan Wilson Senior Coroner for Blackpool & Fylde Dated: 9th May 2014 3
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.
Blackpool Teaching Hospitals INHS| NHS Foundation Trust Trust Headquarters Blackpool Victoria Hospital Whinney Heys Road Blackpool Lancashire FY3 8NR a | 12 June 2014 Mr Alan Wilson HM Corner Blackpool & Fylde Coroner’s Office — Municipal Buildings PO Box 1066 Corporation Street Blackpool FY1 1GB Dear Mr Wilson Re: Regulation 28 Report — Linda Yvonne Fisher. DOB: 16.04.52 Many thanks for your letter dated 9" May 2014 and the attached Regulation 28 Report to Prevent Future Deaths. With respect to your concerns, namely: 1) | That we may rely upon patient’s verbal assessment of their own weight to determine medication dosage. Under the Trust procedural documentation for the prescribing of Dalteparin for treatment of venous thromboembolism the patient's exact weight is not required. The table of dosage (units) to body weight (kg) covers the following: Under 46 kg 46-56 kg 57-68 kg 69-83 kg and over 83kg If a patient is not in a position to be physically weighed, for example they are immobile or in too much pain, but they have capacity to inform the medical staff treating them of their weight, it is acceptable to rely on the patient’s own verbal assessment of their weight. | have taken expert advice from one of my Consultant Haematologists who informs me that for the lady in question the alteration of dosages which we made whilst she was an in-patient would not have had a major effect upon the therapeutic impact of this drug. As you were advised at the Inquest the Ward staff, now, in addition to obtaining verbal confirmation of a patients weight, if it is not possible to weigh the patient, a Mid Upper Arm Circumference calculation is performed (MUAC) in line with the malnutrition Universal Screening Tool (MUST) to assist is establishing an accurate weight. RESEARCH MATTERS AND SAVES LIVES - TODAY’S RESEARCH IS TOMORROWS CARE Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality up to date care. We are actively involved in undertaking research to improve treatment of our patients. A member of the healthcare team may discuss current clinical trials with you. A eee. The Patient Safety 3 ef s § rtormaton | Goic & Cy GY Standard / sage Certified member Chairman: Mr lan Johnson M.A., LL.M. Chief Executive: Mr Garv Dohertv Blackpool Teaching Hospitals NHS Foundatior 2) That a familial history of disease was not recorded in the notes. The Venous Thromboembolism (VTE) assessment tools utilised at the Trust, and indeed nationally as a result of NICE, cover medical and surgical patients alike with slightly different criteria. When a patient is assessed, in either discipline, if one or more of the risk factors are identified then a therapeutic dose of Dalteparin will be administered. The familial history was in fact obtained, albeit not until several days after the patient's admission. The presence or absence of a family history in this situation had no material effect upon our assessment of the index patient’s risk of disease. Even if the question were to have been asked on admission and answered in the positive, the treatment regime would have been exactly the same. | am satisfied that our current risk assessment tool is adequate. Yours sincerely MEDICAL DIRECTOR oe
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