Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0333, written 25 Jul 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jul 2017 |
|---|---|
| Reference | 2017-0333 |
| Deceased | Robert Dymond |
| Coroner | Emma Whitting |
| Coroner area | Coventry |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Coventry and Warwickshire 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Professor Andrew Hardy, Chief Executive, University Hospitals Coventry & Warwickshire NHS Trust, University Hospital, Clifford Bridge Rd, Walsgrave, Coventry CV2 2DX 1 | CORONER | am Emma Whitting, Assistant Coroner for the Coroner area of Coventry 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. http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 | INVESTIGATION and INQUEST On 23 March 2017, | commenced an investigation into the death of Mr Robert Dymond, aged 61. The investigation concluded at the end of the inquest on 20 July 2017. The medical cause of death was found to be: 1a Pulmonary Thromboembolism due to 1b Deep Vein Thrombosis 1c Obesity and Recent Surgery for Knee Replacement The Conclusion of the inquest was a Narrative Conclusion: Died from a recognised complication of surgery. 4 | CIRCUMSTANCES OF THE DEATH On 20 May 2015, Mr Dymond has been placed on the waiting list for elective left knee replacement surgery. As he was considered to be a high risk patient owing to his previous medical history, which included a high BMI of 42.1, he had to undergo this at UHCW which has a Critical Care Unit. He had an initial pre-op assessment on 21 July 2016 and a further pre-op assessment on 12 January 2017. Despite the fact that he had undergone investigation and preliminary treatment for a suspected DVT in November 2016 at UHCW, | was informed that the pre-op assessment in January 2017 had noted no changes since the previous one. The Consultant Orthopaedic Surgeon performing the surgery was not informed of the events in November 2016. The surgery was performed on 9 March 2017. On the morning of 10 March 2017, and despite appropriate post-operative VTE prophylaxis, he suffered a massive thromboembolic event and passed away on 11 March 2017. 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 could 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) Following referral to the UHCW DVT Clinic by his GP on 22 November 2016 with a suspected DVT, Mr Dymond, having a Wells score of 2, was assessed as being ‘likely’ to be suffering from a DVT — the investigations included a D-Dimer blood result of 0.97 — and he was discharged home with instructions to self-administer therapeutic LMWH (Clezane) doses at home twice daily in his stomach pending an ultrasound scan booked for 25 November 2016. The scan performed on 25 November 2016 apparently revealed no evidence of a DVT and he was discharged back to the care of his GP. Although the clinical management appeared to conform with the UHCW protocol in place at the time, this protocol did not appear to conform with NICE Guideline 144 (specifically section 1.1.3) which (since 2012) advises a repeat proximal leg vein ultrasound scan 6-8 days later for all patients with a positive D-dimer test and a negative proximal leg ultrasound scan); (2) Neither the Consultant Orthopaedic Surgeon nor the Anaesthetist performing the operation on 9 March 2017 had been made aware of the DVT investigations/treatment in November 2016; (3) The DVT investigations/treatment in November 2016 did not appear to feature in the second pre-operative assessment carried out on 12 January 2017. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 19 September 2017. |, 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 Mr Dymona's family. | 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. 25 July 2017 SIGNED BY ASSISTANT CORONER: sacks hip
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.
INHS) University Hospitals Coventry and Warwickshire NHS Trust University Hospital Clifford Bridge Road Walsgrave Coventry CV2 2DX 18 September 2017 Direct Line: 024 76967621 Fax: 024 7696 5224 Mrs E Whitting www.uhew.nhs.uk HM Assistant Coroner for Coventry Coroner’s Office Coventry Registrar Office Manor House Drive Coventry CV1 2ND Dear Mrs Whitting Re: Robert _ | write in response to your Regulation 28 Report to Prevent Future Deaths issued on 25" July 2017. The Trust’s Haematology Department devise and manage the Trust’s pathway for the management of the DVTs and would have been pleased to have been given the opportunity of providing you with evidence on this matter at the Inquest. In order to address your concerns their advice has been obtained. As you have stated the NICE guidance refers to the commission of proximal scans, which are taken at the knee level and show the veins at that point. When a proximal scan is undertaken they advise that a repeat scan should be undertaken 6-8 days later when there is a positive D Dimer and a negative proximal scan. The reason that this practice is not adopted by the Trust is because at UHCW, we undertake a more extended scan as a routine which shows the leg veins below the knee to the trifurcation in the calf. This is discussed in NICE guideline 144 section 4.1 which states that whole leg scans do not routinely need a repeat scan. Therefore we believe that the Trust’s pathway goes beyond the minimum requirements and accordingly we experience very low numbers of venous thromboembolism following discharge from the DVT service. Further, the Trust's standard practice in patients with a high risk Wells score and raised D-Dimers is to contact the patient 5-7 days later and arrange a repeat scan if the symptoms are not settling. Only a small proportion of patients who present with isolated distal DVTs extend to the proximal veins. Those that do not extend, rarely lead to clinically significant emboli as recognised by the British Society of Haematology national guidelines, a copy of which is attached by way of information. Chief Executive Officer: Andrew Hardy Chairman: Andrew Meehan The NICE rationale for repeating a scan is to detect those distal clots which have extended into the proximal veins as in this situation the leg symptoms will not resolve and would be anticipated to worsen. Therefore, for that reason patients whose symptoms are resolving are not recommended to have a repeat scan. It is also of note that the Trust use a very high sensitivity D - Dimer kit and the British Society of Haematologists guidance states that patients with a moderate risk Wells score (1-2) can follow the path of low probability if such a test is used. The haematologists do consider it unlikely that the patient did have a proximal DVT as he was untreated and does not appear to have had any further problems up until his surgery 4 months later. As no DVT was identified by the investigations it would not have been relevant to the pre-operative assessment and would not have been relevant to the operating team. We hope this gives assurance that appropriate actions are in place for the management of DVT’s. HS Professor Andrew Hardy Chief Executive Officer Yours sin Chief Executive Officer: Andrew Hardy Chairman: Andrew Meehan
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