Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0169, written 29 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Apr 2015 |
|---|---|
| Reference | 2015-0169 |
| Deceased | Doreen Wood |
| Coroner | Heidi Connor |
| Coroner area | Nottinghamshire |
| Category | Community health care and emergency services related deaths |
| Organisation named | Nottinghamshire Healthcare NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
INQUEST TOUCHING THE DEATH OF DOREEN WOOD
REGULATION 28: CORONER’S REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Practice Manager
Newgate Medical Group
The Health Centre
Worksop
Nottinghamshire
$80 1HP
1 | 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 2 February 2015, | commenced an investigation into the death of Doreen Wood, DoB
25" May 1927. The investigation concluded at the end of the inquest on 23 April 2015.
The conclusion of the inquest was natural causes. The medical cause of death was :
1a Intra-cerebral haemorrhage.
2 Atrial Fibrillation.
4 | CIRCUMSTANCES OF THE DEATH
Mrs Wood had been taking Warfarin since 2013, following a diagnosis of atrial
fibrillation. Her INR was being monitored by her GP practice at the time of her death.
We heard that, in April 2014, her INR was noted to be 8.9 (the normal range being 2 -
3). Mrs Wood was given Vitamin K to reverse the effect of the Warfarin, and her INR
levels were monitored weekly for a number of weeks thereafter.
Mrs Wood was admitted to Bassetlaw District General Hospital on 6” August 2014
following a fall. Her INR was above the normal range. The view of the treating
consultant was that this was probably caused by 3 days of diarrhoea which Mrs Wood
had suffered before her admission. She was discharged to Jubilee Court Nursing Home
on 11" August 2014.
Mrs Wood’s INR was again raised on 29 August 2014, to 9.8. After treatment with
Vitamin K, her INR went down to 1.4.0n 2 September. On the 8” September, her INR
result was 9. Tests carried out on 9" and 10" September gave results of 5.6 and 2.6
respectively.
The test carried out on 10" September was the final INR check before Mrs Wood's
death. The GP. planned to repeat the test again on 4 October, ie 3 weeks later.
iccepted that his colleague who saw Mrs
hould not have waited 3 weeks before her
told us that this should have been done around a week
The GP who gave evidence
Wood on 10"" September 2014
next INR check, {i
later, ie by 17" September.
It was accepted by | various factors affect INR, including weight, diet,
medication and whether a patient is suffering with diarrhoea. He was not able to tell the
court from the records what information was known to the practice about Mrs Wood in
this respect. We heard that, in fact, she did suffer diarrhoea and was losing weight in the
weeks before her death. It is not clear whether the GP was aware of this when he
decided to wait 3 weeks before checking Mrs Wood's INR again.
I could not say, on the balance of probabilities, whether earlier review would have
resulted in a different outcome. | found that the bleed which caused her death was likely
to have been spontaneous. | heard evidence from her treating consultant at Bassetlaw
District General Hospital (whose statement was read in court) that this bleed is likely to
have developed acutely and rapidly, leading to her death on 25" September 2014.
INR monitoring by Newgate Medical Group Surgery
| took evidence from the team leader of the healthcare assistants who were
responsible for taking blood from Mrs Wood for INR testing. They are employed by
Nottinghamshire Health care NHS Foundation Trust. He said that all other GP
practices in the area follow a protocol which includes the completion of a
.. questionnaire,dealing with matters relevant to dosing by the GP. These practices
also take responsibility for informing patients of their dosage decisions.
| heard that Newgate Medical Group surgery adopts a different approach. They
require a face to face discussion with the healthcare assistant when making dosage
decisions, and do not routinely use questionnaires. It was clear that the GPs are
relying to some extent on the healthcare assistants to bring to their attention any
relevant factors, such as those referred to above, on the presumption that the
healthcare assistants know the patients well.
We heard from the healthcare assistants’ team leader about how the task of taking
blood from patients in the community is allocated. He told the court that the
healthcare assistants would simply be allocated the task of attending patients in the
community to take blood, and would not routinely be aware of problems with diet,
weight, etc. They are not medically trained and would not necessarily be aware of
what factors / information would be relevant to tell the GP before dosing decisions
are made.
The GP who gave evidence was not able to point to any benefit in adopting this
system, describing it as ‘simply historical’.
In addition to the concern | have about relevant information being given to GPs to
inform their dosing decisions, it was clear that the system adopted by Newgate
Medical Group surgery creates something of a drain on resources for the healthcare
assistant team. They have to wait in the surgery to see GPs face to face before
dosing instructions are given, and also have to take responsibility for communicating
these to the patient or carer.
This surgery appears to have delegated more of its responsibility for INR monitoring
to the healthcare assistant team than the other 11 practices in this area. | am
concerned that relying on healthcare assistants to volunteer information relevant to
dosing decisions is unsafe. | heard no evidence to justify the fact that Newgate
Medical Group surgery adopts a ‘historical approach’ which is different from other
practices in the area.
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) linvite Newgate Street surgery to review their system of INR monitoring, in
discussion with Nottinghamshire Healthcare NHS Foundation Trust.
(2) Specifically, | invite the surgery to consider the use of standard questionnaires,
and not rely on healthcare assistants to volunteer — or indeed be aware of ~
relevant clinical information to pass on to the GP when dosing decisions are
made.
There has been no internal investigation of these matters within the practice,
other than a discussion between two of the GPs who treated Mrs Wood. We
heard that there are at least six other GPs at the practice who deal with
decisions like this on a regular basis. | invite the practice to carry out its own
internal investigation,to ensure that the learning from these events includes all
GPs at the practice.
(3
=
6 | ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and your
practice 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 25" June 2015. |, 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.
8 | COPIES and PUBLICATION
! have sent a copy of my report to the Chief Coroner and to the following Interested
Persons :
1. Family of Doreen Wood
2. <2: of Quality, Risk and Patient Safety, Nottinghamshire
Healthcare NHS Foundation Trust.
| have also sent it to the following :
1. Phil Mettam, Chief Officer, Bassetlaw Clinical Commissioning Group, North
Road, Retford, Nottinghamshire DN22 7XF
2. NHS England, Birch House, Ransom Wood Business Park, Southwell Road
West, Mansfield, Nottinghamshire NG21 OHJ :
Lam aiso 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.
29" April 2015
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