Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0457, written 23 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Oct 2014 |
|---|---|
| Reference | 2014-0457 |
| Deceased | Phyllis Kerry |
| Coroner | Heidi Connor |
| Coroner area | Nottinghamshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive, Nottingham University Hospitals NHS Trust 1 2. Family of Mrs Phyilis Kerry 3. | Head of Legal Services, Nottingham University Hospitals NHS Trust 4. Chief Coroner 4 CORONER | am Mrs Heidi Connor, Assistant Coroner for the coroner area of Nottinghamshire. 2 | CORONER’S LEGAL POWERS | 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 11 July 2014, | commenced an investigation into the death of Phyllis Kerry, DoB 8 June 1935. The investigation concluded at the end of the inquest on 22 October 2014. The conclusion of the inquest was that the cause of death was : 1a Primary intracerebral haemorrhage 1b Warfarin Treatment 1c Metallic aortic valve and aortic root replacement — ascending aortic aneurysm 2 Hypertension | recorded a narrative conclusion as follows : Phyllis Kerry died after suffering a stroke, which was complicated by the Warfarin medication she was on. 4 | CIRCUMSTANCES OF THE DEATH Mrs Kerry had a history of heart valve replacement and aortic aneurysm, and was on long-term Warfarin. She was admitted to the ED at Queen’s Medical Centre at 1555 hrs on 28" January 2104, with symptoms suggestive of stroke. She was taken for a CT scan at 1733 hrs. The scan showed a bleed consistent with haemorrhagic stroke. The ED consultant liaised with neurosurgery and haematology colleagues. Neurosurgery advice was that nothing could be done surgically, but that the effects of the Warfarin should be reversed, and they should be contacted again if her condition deteriorated. The haematology registrar advised giving Mrs Kerry Vitamin K to reverse the Warfarin. He did not recommend giving Octaplex. He did not discuss the case with his seniors or with neurosurgery colleagues. It was accepted in evidence that Octaplex should have been given, to reduce the effects of the Warfarin more quickly. Mrs Kerry deteriorated, with dropping GCS, and further CT scanning showed that her bleed had increased significantly. After consultation with neurosurgery colleagues, and discussion with her family, a DNAR order was put in place and Mrs Kerry died — her death being confirmed in the early hours of 31° January 2014. The haematology registrar gave evidence that he carried out research of his own on 28 January, using Electronic Medicines Compendium, and came to the conclusion that, because of a risk of clotting, it would be better for Mrs Kerry to be given Vitamin K instead of Octaplex. | took evidence from a consultant physician, who said that NICE and RCP guidelines state that both Vitamin K and Octapiex should be given in cases of intracerebral haemorrhage in patients anti-coagulated with Warfarin or similar drugs. The haematology registrar was not aware of these guidelines, and the consultant physician told us that there are no current trust guidelines which cover this — draft guidelines have been withdrawn but not replaced. talso heard mm =F consultant haematologist not involved with this patient, has reviewed the case and advised all haematology and neurosurgery ST doctors that the responsibility for a decision for i eversal of Warfarin in patients with CNS bleeds lies with neurosurgery. H e that he does not consider this practice has been adopted - that it is simply suggestion — and he does not agree that neurosurgery advice is always necessary in cases like this. It is clear that there would need to be involvement from several specialties in relation to prescribing Octaplex in particular. Crucially, however, | could not be clear, from the evidence | heard, which specialty would ultimately be responsible for deciding when immediate reversal is called for. It was also clear that there was no guideline or protocol in place which the haematology registrar could have consulted. 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) Which specialty takes responsibility for deciding when immediate reversal is needed? (2) The absence of clear guidelines for dealing with patients presenting with intra- cerebral bleeds whilst on Warfarin or similar medication. (3)The communication of relevant guidelines to relevant staff. While none of the witnesses | heard from were aware of any relevant guidelines, it is possible that these may in fact already be in existence. Similarly, it may be that draft guidelines are being reviewed. However it was not clear from the evidence when / if these would be finalised. If there are existing guidelines, it would concern me greatly that the witnesses | heard from were unaware of these, and | take the view that communication of guidelines is as important as the guidelines themselves. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | 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 19 December 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 | have sent a copy of my report to the Chief Coroner and to Mrs Kerry’s family. | am also under a duty to send the Chief Coroner a copy of your response. | will also send this to Mrs Kerry’s family. 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. 23 October 2014
2 responses 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.
Please ask for: Ref: 16 December 2014 Mrs Heidi Connor Assistant Coroner to the Coroner for the Area of Nottinghamshire Queen’s Medical Centre Campus Anaesthetics Directorate Derby Road Nottingham NG7 2UH Tel: Fax: www.nuh.nhs.uk Dear Mrs Connor Re: Preventing Future Deaths Notice – Phyllis Kerry On behalf of Nottingham University Hospitals I am responding to the regulation 28 PFD notice issued following the inquest into the death of Phyllis Kerry. Thank you for bringing this important issue to our attention. Our inquiries have agreed with your observation of a lack of clarity with regard to the reversal of anticoagulation in patients admitted with intracerebral haemorrhage, and also which specialty has ownership of this management. Discussions have been held between the specialties involved to optimise the management of these patients. This has included senior representation from the Emergency Department, Neurosurgery, Stroke services and Haematology. This discussion has referred to the 2008 NICE guidance on the management of acute stroke patients. A new guideline has been prepared which I am confident will provide more rapid intervention in the management of anticoagulation and will clarify which specialty is responsible for this element of care. The specialties involved are currently consulting with colleagues to finally agree the guideline and am conscious that this may not complete by the 19 December 2014 when the PFD response is required. I am confident that the guideline will be ready for circulation by the start of 2015. In addition to sharing with medical staff in the appropriate specialties we will also ask for this guideline to be added to the NUH guideline APP which will assist medical staff to access the guideline whenever required. I hope that these actions will provide assurance that NUH have taken appropriate steps to improve the management and safety of our patients, and to attend to the requirements of this PFD notice. I will send you the agreed guideline as soon as it is available, or if you prefer I can send the version currently under discussion. Please let me know if I can provide any additional information. NUH Deputy Medical Director
Queen’s Medical Centre Campus Specialist Support Directorate Derby Road Nottingham NG7 2UH Tel: Email: Fax: www.nuh.nhs.uk 27th January 2015 Ref: Heidi Connor Assistant Coroner for Nottinghamshire HM Coroner's Service The Council House Old Market Square Nottingham NG1 2DT Dear Mrs Connor Inquest Touching the Death of Phyllis Kerry The new guideline to assist with the prompt and appropriate treatment of patients who are on warfarin presenting with Intra Cranial Haemorrhage has now been agreed by all parties involved and accompanies this letter. I am confident that this guidance will support the NUH staff in managing these patients and reduce delays to urgent treatment. I have asked the Heads of Service for the specialties involved (ED, Stroke Services, Neurosurgery, Haematology) to ensure that this new guideline is communicated to all current medical staff, both trainee and Consultant. This communication will be reviewed by the Medical Directors office to ensure that it is progressed appropriately. I have also asked for this issue to be included in medical staff specialty induction in order to ensure that new staff will also be made aware. I have also asked the NUH guideline group to consider other ways of making the guidance readily available, in particular this will be considered for inclusion within the NUH guideline APP which has widespread use within the NUH. I trust that these measures will assure you of our response to the PFD issued in this respect. If I can provide any further information please let me know Kind regards Deputy Medical Director, NUH.
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