Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0389, written 31 Oct 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Oct 2016 |
|---|---|
| Reference | 2016-0389 |
| Deceased | Frederick Squires |
| Coroner | Thomas Osborne |
| Coroner area | Milton Keynes |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Road (Highways Safety) 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.
Thomas Ralph Osborne
Senior Coroner for Milton Keynes
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: Sir Andrew Dillion, Chief Executive NICE
1
CORONER
I am Thomas Ralph Osborne, Senior Coroner for Milton Keynes
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 15/01/2015 I commenced an investigation into the death of Frederick Squires, 87. The
investigation concluded at the end of the inquest on 13/10/2016. The conclusion of the inquest
was a Narrative conclusion as attached.
4
CIRCUMSTANCES OF THE DEATH
On 4th December 2014 Mr Squires was involved in a road traffic collision where he was struck by
the rear of a slowly reversing vehicle. The collision was low impact but on falling to the floor, Mr
Squires struck his head. He was taken to Milton Keynes Hospital where a CT was performed
and his warfarin and medications were stopped. He was admitted to ward 19 on 5th December
2014 and was discharged home on 6th December 2014 with instructions to see his GP as an
outpatient to arrange another CT scan and he was not to start taking his medications until the
results of the second CT scan were available. His second CT scan was booked for 29th
December 2014.
Early on the morning of the 21st December 2014 the deceased was found on the toilet in the
bathroom. An ambulance was called and the deceased was taken to the Luton and Dunstable
hospital where a CT scan of his head showed he had an acute ischaemic stroke. He died on the
30th December 2014.
has maintained that she was concerned at the withdrawal of
all his medications and had expressed this on several occasions.
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In that
there was no clear indication as to whether the warfarin should only be started after a further CT
scan or after the period of 14 days regardless of a scan. In my opinion there is a risk that future
deaths will occur unless action is taken to give clear guidance. In the circumstances it is my
statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
(1) That there is no guidance available to clinicians as to when Warfarin should be recommenced
for a patient who has suffered a head injury. If clear guidance is not available it will lead to
confusion amongst clinicians and the patient with the result that it is commenced too soon and
the patient develops a bleed or too late and the patient suffers a stroke.
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ
Tel 01908 254326 | Fax 01908 253636
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
26th December 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 Persons
- The family of Mr Squires
I have also sent it to CQC who may find it useful or of interest.
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
Dated 31st October 2016
Signature_________________________
Senior Coroner for Milton Keynes
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ
Tel 01908 254326 | Fax 01908 253636
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.
RECEJVED ] 0 1 DEC 2016 10 Spring Gardens London SW1A2BU United Kingdom K I I f E National Institute for 1 1 1 w C Health and Care Excellence 23 November 2016 Thomas Ralph Osborne, Senior Coroner H M Coroner’s Office Civic Offices 1 Saxon Gate East Central Milton Keynes MK9 3EJ Dear Mr Osborne, I write in response to the Regulation 28 Report into the death of Mr Frederick Squires. I was very sorry to learn of Mr Squires’ death. You explain in your report that there is no guidance available to clinicians as to when Warfarin should be recommenced fora patient who has suffered a head injury. You subsequently have concerns that if clear guidance is not available it will lead to confusion amongst clinicians and the patient, with the result that it is commenced too soon and the patient develops a bleed, or too late and the patient suffers a stroke. We have considered the circumstances around Mr Squires’ death and the concerns you have raised. We have a guideline on the assessment and early management of head injury (accessible from our website: www.nice.org.uk/cg176), which includes recommendations regarding discharging patients. However, we believe that to examine the available evidence and make specific recommendations on when to restart Warfarin would require the guideline’s scope to be extended. We will consider the case for doing so, when we consider the guideline for updating in 2017 Yours sincerely, Chief Executive www.nice.org.uk | nice@nice.org.uk
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