Captain James Bedforth

Gawber Road 
Barnsley  
S75 2EP 

Tel: 01226  730000 
Fax: 01226  202859 
Minicom: 01226  321014 

Direct contact: 
Tel: 

e-mail: 

4 January 2017 

Mr C P Dorries 
Senior Coroner 
South Yorkshire West Area 
Medico Legal Centre 
Watery Street 
Sheffield 
S3 7ES  

Our Reference: RJ/KAD - Captain Bedforth 
Your Reference: CPD – Regulation 28 – Captain Bedforth 

Dear Mr Dorries  

Captain James Bedforth Inquest - Regulation 28 Prevention of Future Death Response 

I am writing in response to your Regulation 28 Report to Prevent Future Deaths received at 
the Trust on Tuesday 25 October 2016 relating to the inquest of Captain James Bedforth. 

Regarding our response I will follow the same numbering as set out in your report, I will not set 
out each of your concerns but respond to them below. 

1. The current NICE guidance for Venous Thromboembolism advises proximal leg USS 
investigation for those patients who are high risk based on Wells scoring and those who are 
low risk with a positive D-dimer. If negative, the patient should undergo a second proximal leg 
USS in 6-8 days time to exclude proximal propagation of a clot from a distal DVT. The 
rationale behind the NICE guidance is evidence-based following multiple studies. 

The hospital has decided it will not change its processes on the basis that in Captain 
Bedforth’s case it would be more likely than not that the distal leg USS would not have had 
any impact as distal leg USS does not detect all DVTs that are present. No combination of 
tests can rule out disease in 100% of cases and a lower leg scan may also have been falsely 
reassuring. It is evident from this particular case that consideration could have been given for 
treating Captain Bedforth despite the normal USS given that this case may be one of that 
small minority of cases where USS is falsely negative. However, treating patients without 
confirmatory evidence of a DVT creates a separate set of risks as this would expose 
significant numbers of patients to unnecessary anticoagulation.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                   
                     
         
 
 
 
 
 In relation to your concern regarding the discharge of a patient like Captain Bedforth following 
a negative scan and whether he requires close supervision by a doctor, this practice is already 
in place and is triggered by the Thrombosis nurse. The process is that if the Thrombosis 
Service Sister has concerns regarding a patient they are referred to the consultant for review 
in the DVT clinic. The Thrombosis Sister has stated that Captain Bedforth’s case is the first 
case of its kind she has been aware of in the last 15 years. We will be interested to see 
whether national guidance changes following your letter and would adapt our local guidelines 
accordingly, if so. 

2. There is a Patient Information Sheet for patients who have attended hospital for 
investigation for deep vein thrombosis or pulmonary embolism. (Attached) This sheet is 
handed to all such patients at discharge, along with verbal advice provided by our specialist 
nurses. The Thrombosis nurses now record in their notes that an information sheet has been 
given to the patient. This will be audited to assess compliance. 

3. In the Emergency Department (ED) there is now a consultant in the new assessment hub 
area, which should speed up the diagnosis and management of someone presenting in this 
way. The Short-Term Assessment of Risk and Treatability Hub (START) runs between the 
hours of 09:00 and 16:00 hours and is consultant led. The START consultant will provide a 
senior ‘front of house’ service to assist with the initial assessment and ensure the appropriate 
diagnostic testing is undertaken at the earliest opportunity. The Consultant will work alongside 
the assessment hub staff in ensuring a safe and rapid assessment process. The consultant 
predominantly receives patients arriving by ambulance, however patients that also ‘self 
present’ can be seen on START, if they are unwell, have an elevated NEWS score or require 
treatment within one hour. 

4. We have and continue to ensure there are sound processes in all clinical areas regarding 
prompt escalation of unwell patients. This is covered on the induction programme for all 
medical students who are very familiar with the need to escalate if they see someone who is 
acutely unwell. We have also recently introduced an Acute Response Team of Advanced 
Nurse Practitioners who rapidly attend to support wards with patients who deteriorate. We 
have also invested in the VitalPac electronic observation system that has been demonstrated 
in other Trusts to improve the recognition and response for sick patients. 

5. The Trust has altered the Thrombolysis PE guideline – amongst the changes we have 
addressed the concerns about checking whether heparin had been administered previously 
and to carefully check and monitor the APTT ratio. A copy of the revised guidance is attached 
for your information 

In relation to your query surrounding the time taken for sampling to be delivered to the 
laboratory and provision of the result, this query was covered in the Serious Incident (SI) 
investigation report and I quote that part of the SI Report for your assistance. 

“The sample for APTT testing was timed as being collected from ICU at 19.58hrs, but 
the sample was not taken until 21.15hrs and not received by pathology until 21.24. The 
results were reported to ICU at 22.35hrs, so an apparent delay of 2 hours and 37 
minutes seemed to have occurred.  

However, when the Lead Nurse on ICU was asked about this as part of the SI 
investigation, she explained that ICU staff pre-prepare for testing of bloods, which was 
why the test indicated the time 19.58hrs.” 

Page 2 of 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 This means that the form was completed in advance at 19:58 hours and the time taken from 
collection to report was actually 1 hour 20 minutes not 2 hours 37 minutes. 

6. The new Thrombolysis protocol (see point 5) prompts the doctor to ensure that heparin hasn’t 
already been given, for example in the ED. We aim to introduce an electronic prescribing system in 
2017 that would allow doctors to more easily identify what drugs have already been given.   

I hope the above is of assistance, if you wish to discuss this matter please do not hesitate to contact 
me. 

Yours sincerely 

Medical Director 

Enc 

Page 3 of 3

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

The Secretary of State for Health 

1 

CORONER 

Christopher Dorries, senior coroner for South Yorkshire (West) 

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. 

(1) 

Where –  

(a)  A senior coroner has been conducting an investigation under this Part into a 

person’s death and 

(b)  Anything revealed by the investigation gives rise to a concern that 

circumstances creating a risk of other deaths will occur, or will continue to 
exist, in the future, and  

(c) 

In the coroner’s opinion, action should be taken to prevent the occurrence or 

continuation of such circumstances, or to eliminate or reduce the risk of death 
created by such circumstances, the coroner must report the matter to a 
person who the coroner believes may have power to take such action. 

(2) 

(3) 

A person to whom a senior coroner makes a report under this paragraph must 
give the senior coroner a written response to it. 

A copy of a report under this paragraph, and of the response to it, must be sent 
to the Chief Coroner 

INVESTIGATION and INQUEST 

On 30th June 2015 I commenced an investigation into the death of Captain James 
Michael Bedforth. The investigation concluded at the end of the inquest on                   
7th September 2016. The conclusion of the inquest was that Captain Bedforth died from 
1(a)   Cerebral haemorrhage 
1(b)   Significant pulmonary embolus and paradoxical embolus to the brain (treated) 
1(c)   Deep vein thrombosis (left) 
A narrative conclusion was recorded as follows: 
Captain James Michael Bedforth died at the Barnsley Hospital on 30th June 2015 in 
consequence of treatment given to him, in accordance with the hospital protocol, for a 
pulmonary embolus including a paradoxical embolus to the brain. 

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4 

CIRCUMSTANCES OF THE DEATH 

Captain Bedforth was a senior long haul airline pilot.  Such an occupation obviously 
involves prolonged seated immobility although there is some opportunity for movement. 
On the 18th April 2015 he attended the hospital at Barnsley with pains in his left leg 
around the knee.  Appropriate investigations were made (in accordance with NICE 
guidelines) which included scanning of the upper but not lower leg.  Nothing was found 
and Captain Bedforth was discharged. 
On 29th June 2015 Captain Bedforth collapsed at his home some hours after a flight 
from China.  He was admitted to the hospital with classical symptoms of a DVT but 
further collapsed a few hours later and was treated with Alteplase.  A CT scan showed 
pulmonary embolus and an early left sided cerebral infarction due to a paradoxical 
embolism.  Heparin treatment was subsequently given (and stopped at 2235).  The 
Captain deteriorated markedly after a seizure at 2345.  A further CT showed an 
unsurvivable left sided acute cerebral haemorrhage. The inquest found a strong 
inference that this had arisen from over-anticoagulation with Heparin.  Death occurred at 
1145 the following morning 30th June 2015.  

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 MATTER OF CONCERN for the Secretary of State to consider is as follows: 

The inquest heard that the scanning practice followed after the first attendance was in 
accordance with NICE guidelines (indeed possibly a little in excess of the guidance) 
which did not include scanning of the lower leg.  This was said to be on the basis that 
not all lower leg DVTs will be visible.  Yet it became apparent that that there is mixed 
practice on this point, some hospitals clearly consider that lower leg scanning is 
worthwhile. 

Hindsight strongly suggested that Captain Bedforth was developing clots in the left lower 
leg at the time of the first visit.  The inquest found that a full leg scan might have 
provided the hospital with an opportunity to treat Captain Bedforth although it was 
accepted that no-one could be certain of this. 

The Secretary of State for Health is asked to consider whether it is appropriate for 
further research to be conducted as to the question of lower leg scanning. 

Note that a separate Regulation 28 report is being sent to The Chief Executive at the 
Hospital in Barnsley relating to 'safety netting' on the first visit, possible delay following 
the second admission and anti-coagulation practice. 

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.  

2

 
 
 
 
 
 
 
 
 7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 4th January 2017.  I may extend this period, if asked, particularly given the 
Christmas break. 

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 
Persons: 

The family of Captain Bedforth 
The Chief Executive, Barnsley NHS Foundation Trust 
The Civil Aviation Authority 
British Airways 
The Care Quality Commission 

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 at the time of your response, 
about the release or publication of your response by the Chief Coroner. 

9 

18th October 2016                           Christopher P. Dorries OBE 

HM Senior Coroner 
South Yorkshire (West) 

3

RR Philip Dunne MP

Minister of State for Health

Department
of Health
Richmond House

Our ref: 1055768 79 Whitehall
Your ref: swin one
Mr Christopher Dorries Tel 020 7210 4890
HM Senior Coroner
South Yorkshire (West)
The Medico-Legal Centre
Watery Street
Sheffield
S3 7ET

22 February 2017

Thank you for your letter of 18 October 2016 following the inquest into the death of
Captain James Michael Bedforth. I am responding as the Minister with responsibility
for hospital care at the Department of Health.

I was sorry to hear of Captain Bedforth’s death. Please extend my condolences to his
family and loved ones.

Your report explained that Captain Bedforth attended hospital in Barnsley on 18 April
2015 with pains in his left leg around the knee. Appropriate investigations were made
(in accordance with NICE guidelines) which included scanning of the upper but not
lower leg. Nothing was found and the patient was discharged.

On 29 June 2015 Captain Bedforth collapsed at his home following a long flight. He
was admitted to hospital with symptoms of Deep Vein Thrombosis (DVT) where his
condition worsened. Following a CT scan Captain Bedforth was treated with Heparin,
but his condition deteriorated markedly after a seizure late that evening. A further CT
scan showed an unsurvivable left sided acute cerebral haemorrhage. The inquest found
a strong inference that this had arisen from over-anticoagulation with Heparin. Captain
Bedforth died the following morning, 30 June 2015.

You asked that the Department of Health considers whether it is appropriate for
further research to be conducted as to the question of lower leg scanning.

The inquest heard that the scanning practice followed after Captain Bedforth’s first
attendance in April 2015, was in accordance with NICE guidelines which do not
include scanning the lower leg. As it became apparent there is mixed clinical practice
on this point, your view is that some hospitals consider that lower leg scanning is
worthwhile. As most hospitals are, or should be, working to NICE guidelines, I
therefore advised that you should consider inviting NICE to respond to this case
directly. My officials provided you with contact details and I understand that NICE are
looking into this and will respond directly to you and copy me into their reply. I have
also consulted the Royal Society of Medicine Venous Forum (RSMVF) and asked for
their comments on this case. RSMVY advises that it is not possible, without full
clinical details on Captain Bedforth’s case, for them to comment on the specifics or
ascertain whether the detailed recommendations of NICE clinical guidelines (CG144)
were followed.

However, RSMVF also points out that the evidence for treating distal DVT alone is
weak and cites a recent CACTUS trial (lancet haematology 2016) which showed no
benefit in treating symptomatic below knee DVT. RSMVF is of the opinion that that
even if Captain Bedforth had had a full leg scan, and had been found to have a below
knee DVT in April 2015, the evidence is not clear on whether he should have been
immediately anticoagulated at that time.

As such RSMVF also recommend that these issues be referred to NICE for comment
as the type of scanning used for these investigations originated with the NICE
guideline (CG144).

I hope this reply is helpful and I am grateful to you for bringing the circumstances of
Captain Bedforth’s death to my attention.

I am copying this letter to Sir Andrew Dillon, Chief Executive of NICE.

PHILIP D