Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0359, written 4 Dec 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Dec 2017 |
|---|---|
| Reference | 2017-0359 |
| Deceased | Gordon Thornhill |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Doncaster and Bassetlaw Teaching Hospitals NHS Foundation 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.
for South Yorkshire (East District) _—— ——eeeeeSSSSSSSSSSSSSSMMSSsFhFeFeseFseF REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Sewa Singh, Medical Director, Doncaster Royal Infirmary 1 CORONER | am Ms NJ Mundy, Senior Coroner for South Yorkshire (East District) 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./Awww.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 24/04/2017 | commenced an investigation into the death of Gordon Frank Thornhill, 61 years. The investigation concluded at the end of the inquest on 27 November 2017. The conclusion of the inquest was natural causes. Gordon Frank Thornhill died on 13 April 2017 when a period of significantly reduced incapacity led to DVT development and death from pulmonary embolism. 4 CIRCUMSTANCES OF THE DEATH A 61 year old man who developed abdominal pain at times radiating to his shoulder and lower back. He had attended at DRI A & E on 4" April 2017 and was discharged on 6" April. He attended A & E again on 8” April 2017 was seen and discharged. He then collapsed and died at home on 13” April 2017. | heard evidence from Mr Hossenbux, Consultant in Emergency Medicine that the VTE risk assessment had not been completed. On subsequently reviewing notes it appeared it had been partially completed. In any event, | was told that this is a mandatory assessment which must be undertaken for all admitted patients. The partially completed VTE risk assessment had the box ticked as Mr Thornhill been at high risk for VTE and was for thromboprophylaxis but despite this it was over 24 hours before that prophylaxis was administered. 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 MATTERS OF CONCERN are as follows. — (1) Junior doctor's failure to fully complete the mandatory VTE risk assessment. (2) The Consultant's VTE assessment done the day following admission failed to identify incomplete/failure to complete VTE risk assessment. (3) The Consultant carried out his own assessment as a “mental exercise” and did not document his assessment. (4) A delay in excess of 24 hours in providing thromboprophylaxis. a Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you Mr Sewa Singh, Medical Director, Doncaster Royal Infirmary 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 the 22 January 2018. |, 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 Lhave sent a co ief Coroner and to the following Interested Persons: family members. | 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. SSS Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365
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.
We ‘ Care “@ i Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Doncaster Royal Infirmary Armthorpe Road, Doncaster South Yorkshire DN2 SLT Medical Director’s Office Tel: 01302 366666 Fax: 01302 320098 Mr S Singh, Medical Director (644156) os Mr RJ Cuschieri, Deputy Medical Director — Clinical Standards (642150) Minicom: 01302 553140 Dr R Harris, Deputy Medical Director — Professional Standards (642124 or 75 2275) (only for people who are deaf) Karen Humphries, Clinical & Professional Standards Co-ordinator (642149) Jacqueline Ford, Executive PA to Medical Director (644148) www.dbh.nhs.uk Ref: NJM/jh/52993-2017 8 January 2018 Ms N J Mundy H M Coroner Coroner’s Court and Office Crown Court College Road Doncaster DN1 3HS Dear Ms Mundy Re: Gordon Frank THORNHILL (Deceased) | write in response to the Regulation 28 Report “Prevention of Future Deaths” dated 4 December 2017 sent to the Chief Executive of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust and for which | thank you. | note your concerns as follows; 1, Junior doctors failure to complete the mandatory VTE risk assessment 2. The Consultants VTE assessment done the day following admission failed to identify incomplete/failure to complete VTE risk assessment 3. The Consultant carried out his own assessment as a “mental exercise” and did not document his assessment 4. A delay in excess of 24 hours in providing thromboprophylaxis | would respond as follows; 1. The Trust has a policy entitled Venous Thromboembolysm (VTE) — Prevention and Treatment of VTE in Patients Admitted to Hospital. This policy is available on the intranet and has been in place since July 2014. It is currently being reviewed to take into consideration the changes within the organisation but the essence of the prevention policy will remain intact. The policy clearly identifies the role that individuals have in assessing and ensuring that patients receive the appropriate prophylaxis. | enclose a copy of the policy. 2. 1am advised by the Director of Education that VTE prophylaxis is addressed at induction and there is an electronic package approved by Health Education England which trainees have to complete for their annual review (ARCP). This is monitored through the post graduate schools on behalf of Health Education England. This should be supplemented by on-site support and monitoring by consultants. In light of the events that you highlight | have personally written to all consultants and associate specialists advising them of the importance of ensuring that VTE assessments are completed and documented on the post- take ward round and to that end to provide the required support for trainees. 3. | am advised by the VTE Lead for the Trust that the junior staff also receive reminders with respect to completing the assessments and prescribing the appropriate prophylaxis. 4. The Trust has a system of medicines reconciliation for acute admissions on the medical assessment unit and the pharmacists are actively involved in ensuring that this process runs smoothly and also highlighting whether prophylaxis has been prescribed. On this occasion the prophylaxis was prescribed but due to human error it was prescribed to commence on the following day. The message of timely prescription has been reinforced. 5. | am advised by the VTE Lead for the Trust that there is currently a quality improvement project being undertaken on the medical assessment unit to ensure greater compliance with the medical VTE risk assessment form and to ensure that this is reviewed on the post-take ward round and where appropriate prophylaxis is actually prescribed and given in a timely manner. 6. Finally the Trust is in the process of re-launching the “Stop the Clot” campaign which was successful in the early years in ensuring VTE prophylaxis was appropriately undertaken and in a timely manner. This will include strategically placed posters in ward areas and the education centre as well as use of the Trust’s communication systems (Buzz, Risky Business) to highlight the importance of risk assessment and prescription of prophylaxis. The same message will be on the Intranet. | trust that the contents of this letter will reassure you that the Trust takes VTE prophylaxis most seriously and that processes are in place to ensure that doctors have the appropriate competence and understanding to assess and prescribe prophylaxis where appropriate. Please do not hesitate to revert back to me should you feel that there are still any outstanding issues/ “I Aes i J. Cuschieri MD. ChM. M. nk Deputy Medical Director - Clinical Searards Enc. Trust VTE Policy Cc
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