Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016 – 0292, written 16 Aug 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Aug 2016 |
|---|---|
| Reference | 2016 – 0292 |
| Deceased | Harry Glibbery |
| Coroner | Andrew Cox |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Plymouth NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
ANDREW JAMES COX Assistant Coroner for Plymouth Torbay and South Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: | Medical Director, Plymouth Hospitals NHS Trust, Derriford, Plymouth CORONER lam ANDREW JAMES COX, Assistant Coroner for Plymouth Torbay and South Devon 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. http://Awww.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://Awww.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 15/04/2016 | commenced an investigation into the death of Harry Glibbery. The investigation concluded at the end of an inquest on 15 August 2016. The narrative conclusion of the inquest was that Mr Glibbery died from a known complication (bleeding) of a necessary medical procedure (anti-coagulation) 4 CIRCUMSTANCES OF THE DEATH Mr Glibbery suffered with a chronically infected left total hip replacement. He was under the care of a Consultant Orthopaedic Surgeon whose efforts were greatly appreciated by the family. Mr Glibbery had a number of wash-outs as well as two first-stage revisions. On 26th February 2016 he underwent a Girdlestone procedure. On 4 March Mr Glibbery complained of shortness of breath and chest pain. A CT PA on 8 March revealed multiple pulmonary embolii as a consequence of which Mr Glibbery was started on Clexane. At Inquest | was advised that the Derriford Protocol provides for patients to be prescribed 1.5 milligrams per 1 kilogram once daily. As a matter of fact, | found that Mr Glibbery was prescribed 1 milligram per kilogram administered twice daily. Upon admission into hospital Mr Glibbery weighed 80 kilograms and, as a consequence, he received 160 milligrams of Clexane daily instead of 120 milligrams. | was advised that the prescription was reviewed on 3 separate occasions by Pharmacy clinicians but the error was not identified. On 5 April Mr Glibbery deteriorated acutely and a CT scan revealed a catastrophic intracerebral haemorrhage from which he died on 7 April 2016. As a matter of fact | found that the over-administration of Clexane did not cause the death but it may have contributed to the outcome in the sense that once the intracerebral haemorrhage started it bled more profusely that would otherwise have been the case. 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) The doctor who originally prescribed the Clexane did not do so in accordance with Derriford Protocol; 2) The doctor's prescription error was not identified during Pharmacy reviews intended to 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax up precisely this sort of shortcoming; (3) | was advised that during Mr Glibbery’s admission he lost_a substantial amount of weight estimated at between 6 — 10 kilograms. (who gave evidence) expressed their difficulties in having patients weighed. This is particularly difficult for patients who have undergone hip replacements where, | was told, a hoist that is available is not high enough to return patients back to their beds. The importance of this is obvious in patients whose medication is weight-dependent. It is believed that Mr Glibbery was on the cusp of requiring a downward review of the amount of Clexane prescribed to him. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Dr. P Hughes 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 10 October 2016. |, 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 the following Interested Persons - wife of the deceased. | 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. Dated 16 August Signature Assistant Coroner Yo Plymouth Torbay and South Devon 1 Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 | Fax
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.
Plymouth Hospitals NHS) NHS Trust MBBS MRCP FRCR Medical Director and Cons Radiologist Department of Clinical Management, Level 7 Derriford Hospital, Plymouth, Devon PL6 8DH Tel: 01752 439488 Fax: E-mail: 11" October 2016 PRIVATE & CONFIDENTIAL Mr A J Cox Assistant Coroner Her Majesty’s Coroner for the County of Devon Plymouth, Torbay and South Devon 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ Dear Mr Cox Re: Harry GLIBBERY Thank you for your letter of 16" August 2016 outlining a Regulation 28 notice in relation to the aforementioned patient. You have identified a number of points in your letter which | will respond to in order. 1. The doctor who originally prescribed the Clexane did not do so in accordance with Derriford protocol. We have reviewed the records and can identify that the original prescription of Clexane was in the form of prophylactic treatment at 40 milligrams once a day, and this dose was continued for some months from the patient's admission in January until he developed a pulmonary embolism in March 2016. At this point he was commenced on a therapeutic dose of Clexane at 80 milligrams twice daily (160 milligrams total in the day). This is at variance with the Trust’s protocol of 120 milligrams once a day, which is | would point out dependant on weight. This dose was continued, but on review it would appear that on 21* March the patient's weight had reduced from 83 kilograms to 75 kilograms and at this time it would have been appropriate to have reduced the dose to 100 milligrams once a day. The dose was therefore higher than expected but still at the extreme of therapeutic dosage. Working in Partnership with the Peninsula Medical School Chairman Chief Executive: Ann James There are currently three protocols for the use of “therapeutic” Clexane (i.e. not prophylactic use) — DVT / PE protocol; “Bridging therapy” protocol for patients that are routinely prescribed warfarin prior to admission; protocol for the management of Acute Coronary Syndrome. In response to this incident, these protocols will be reviewed by the Thrombosis Committee and clear guidance disseminated across the Trust. Furthermore, the Trust will be investing in the implementation of an electronic prescribing and medicines administration (ePMA) system during 2017. This system will include the use of “order sets” linked to diagnosis, which will ensure that the correct protocol is chosen. For weight specific dosing the patient’s weight will have to be entered in to the system and the dose will be automatically calculated. It will be possible for this functionality to be time limited, such that a new weight would have to be entered at a defined point in time (e.g. every 7 days) and a new dose calculated. . The doctor's prescription error was not identified during pharmacy reviews intended to pick up precisely this sort of shortcoming. Your assertion is correct. We have reviewed the pharmacist that checked this - there were at least two pharmacists and we believe that the secondary pharmacist had accepted that the primary review had confirmed that the dose of Clexane was correct. There is no record of whether the initial pharmacist had challenged / confirmed the dose of Clexane being at variance with the DVT / PE protocol. In response to this incident we have developed a learning package which is being delivered by the Deputy Senior Pharmacist to all pharmacists within the department emphasising the following points: |. Correct dose of 120 milligrams BD. Il. The fact this this is weight dependant. Difficulties in weighing patients following operations which could result in a failure to appreciate a significant loss of weight which would modify medication dosage. In addition, steps are being taken to ensure that the pharmacists make appropriate records in the medical notes when challenging / confirming treatments. In the future, this will be required to be input into the ePMA system. All patients are screened on admission using the MUST assessment tool to identify patients who are malnourished, or at risk of becoming malnourished. All patients are then weighed weekly during their hospital admission, and this is recorded on the MUST Risk Assessment document. The weights are currently updated not on the Drug Chart but on the Observation Chart and at the time of the ward rounds when patients information, clinical circumstances are discussed between medical and nursing staff, any significant changes in weight are discussed and any modifications made as a secondary step to the pharmacist updating the Drug Chart. As highlighted above, with the implementation of ePMA (2017) it will be possible to set time limits for weight dependant drugs, so that a new weight has to be recorded at pre- defined points in time. This will ensure the doses of drugs are always matched to an accurate and up to date weight. In relation to weighing patients who have had operations, this can be difficult particularly with hip operations because of the risk of damaging the hip with a hoist system and secondly that the hoist with the weighing scales in place does not clear the beds. We have discussed this with the nursing staff and identified the importance of these weight Working in Partnership with the Peninsula Medical Schoo! Chairman: fF Chief Executive: Ann James measurements being taken, even if there are considerable technical issues. We will monitor this with the Senior Nurses. This does represent significant challenges, both as a result of the patient's condition and the various mechanisms which are common to patients in this particular. Medical Director Working in Partnership with the Peninsula Medical School Chairman; Chief Executive: Ann James
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