Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0047, written 12 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Feb 2016 |
|---|---|
| Reference | 2016-0047 |
| Deceased | Margaret Hions |
| Coroner | Jonathan Layton |
| Coroner area | Carmarthenshire and Pembrokeshire |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive of West Wales General Hospital Glangwili Carmarthen 1 CORONER I am Jonathan Mark Layton senior coroner, for the coroner area of Carmarthenshire and Pembrokeshire. 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 3rd September 2013 I commenced an investigation into the death of Margaret Hions . The investigation concluded at the end of the inquest on 12th February 2016. The conclusion of the inquest was a narrative conclusion namely that: Margaret Hions died on 27th August 2013 from pulmonary infarction and coronary artery atherosclerosis in an elderly woman who had sustained breakdown of a left gluteal haematoma caused by tinzaparin therapy. There were shortcomings in the management of her care at Glangwili Hospital. 4 CIRCUMSTANCES OF THE DEATH (1) Mrs Hions was admitted to Glangwili Hospital on 1 July 2013 with increasing shortness of breath, decreased mobility, loss of appetite, nausea and vomiting. At the time of her admission she was prescribed warfarin. A decision was made to replace warfarin with tinzaparin. (2) Mrs Hions remained in hospital and during her admission a large bruise was observed which expanded rapidly. (3) As a result of this the tinzaparin was stopped. (4) Mrs Hions was subsequently transferred to the Prince Philip Hospital where she passed away on 27th August 2013. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed this matter 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 is as follows: (1) That there should be a review of the current Health Board practice in the prescribing of tinzaparin medication and the monitoring of blood levels. (2) That the importance of monitoring creatinine clearance as per Health Board clinical pharmacy policy to be reiterated to medical team and pharmacists. These matters were identified by a Root Cause Analysis Investigation report but it was unclear at the inquest whether these recommendations have yet been acted upon. 1 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 the 8th April 2016. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Person: 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. 9 12 February 2016 Signed: 2
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.
G IG Bwrdd lechyd Prifysgol
- Hywel Dda
Os, 0 7 N HS University Health Board
Rhadbost RTJR-ZKJG-JZTC
Gwasanaethau Cefnogi Cleifion
Ein cyf/Our ref: LOCIPKICO Bwrdd lechyd Prifysgol Hywel Dda
Gofynnwch am/Please ask for. Louise O’Connor {feol Abergwaun, RWLEFORDD
Rhif Ffn ‘Telephone: 0300 0200 15¢ j
E-bost/E-mail: Louise.o'connor@wales.nhs.uk Freepost RTUR-ZKJG-JZTC
: Patient Support Services
Date: 29 March 2016 Hywel Dda University Health Board
Fishguard Road, HAVERFORDWEST
SAG1 2PZ
Private & Confidential
Mr M Layton :
Senior Coroner for Pembrokeshire & Carmarthenshire |
Coroner's office
Town Hall
Hamilton Terrace
Milford Haven
Pembrokeshire SA73 3JW
Dear Mr Layton
Inquest touching the death of Mrs Margaret Hions
Thank you for you correspondence, enclosing the Regulation 28 report,
following the inquest of Mrs Hions.
I apologise for the shortcomings in her care that were identified as part of the
inquest and investigation into Mrs Hions death, namely the prescribing of
Tinzaparin and the monitoring of creatinine in accordance with Health Board
policy.
In relation to the recommendation to review Health Board practice in the
prescribing of tinzaparin medication and monitoring of blood levels, I can
confirm that this has been reviewed and a revised guideline for prescribing and
monitoring low molecular weight heparin had been produced. This is currently
subject to consultation within the Health Board and will be presented to the
next scheduled meetings of both the Medicines Management Group and Clinical
Policy Review Group for approval.
The importance of monitoring creatinine clearance is being reiterated by fetter
from the Medical Director to all clinicians and clinical pharmacists; this will also
be included in the Medicines Management Group newsletter which is widely
circulated and by global e-mail to all staff, upon approval of the above
guideline.
‘a ‘il Cadeirydd / Chair
Swyddfeydd Corfforaethol, Adeilad Ystwyth, Corporate Offices. Ystwyth Building, ¥ 4
Hafan Derwen, Parc Dewi Sant, Heo! Ffynnon Job, Hafan Derwen, St Davids Park, Job's Well Road, ‘Mrs Bernardine Rees OBE
in, Sir Gaerfyrddin, SA31 3BB Cc ire, SA31 3BB .
Caertyrddin, Sir Gaerfyrddin, 3! armarthen, Carmarthenshire, S, ; Prif Welthredwr/Ghief Executive
Mr Steve Moore
If you require any further information, please do not hesitate to contact me or
Louise O’Connor, Assistant Director (Patient Experience) on the above contact
number/e-mail. |
Yours sincerely
Kener hues
Steve Moore
Chief Executive
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