Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0079, written 6 Mar 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2018 |
|---|---|
| Reference | 2018-0079 |
| Deceased | Georgia Polydorou |
| Coroner | Sarah Bourke |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| 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.
Coroner ME Hassell HM Senior Coroner Inner North London REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Sir Andrew Dillon Chief Executive National Institute for Health and Care Excellence 10 Spring Gardens London SW1A 2BU Martin Kuper Medical Director Homerton University Hospital Homerton Row London E9 6SR CORONER | am: Assistant Coroner Sarah Bourke Inner North London Poplar Coroner’s Court 127 Poplar High Street London £14 OAE 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. INVESTIGATION and INQUEST On 19 September 2017, | commenced an investigation into the death of Georgia Polydorou who was born on 12 July 1937. The investigation concluded at the end of the inquest, which was conducted by me on 29 January and 6 March 2018. The conclusion of the inquest was a narrative conclusion. | recorded a medical cause of death of: 1a ventilator associated bronchopneumonia 1b subdural haematoma (operated 11.7.2017) 1¢ fall 2 mitral valve regurgitation, atrial fibrillation, hypertension, congestive cardiac failure and Beta trait thalassaemia. CIRCUMSTANCES OF THE DEATH Mrs Polydorou was an in-patient at Homerton University Hospital due to an exacerbation of congestive cardiac failure. She was recognised to be at increased risk of falls. She was prescribed aspirin, clopidogrel and enoxaparin during her admission. In the early hours of 10 July 2017, Mrs Polydorou fell whilst going to the toilet. She was reviewed by the on call doctor and subject to neurological review every 15 minutes for the first hour and hourly observations thereafter. Her Glasgow Coma Score following the fall was 15/15. It was decided that a CT scan would be undertaken if Mrs Polydorou showed signs of deterioration such as headache, bleeding, dizziness or vomiting. Later in the day, she was reviewed by a junior doctor. As she had had 10 sets of normal neurological observations, a decision was made to revert to standard nursing observations. Mrs Polydorou told family members that she had a headache but she did not mention this to hospital staff. At 6.40 am on 11 July, a nurse went to take Mrs Polydorou’s observations and found her unresponsive but breathing. An urgent CT scan showed a large right sided acute subdural haematoma. Mrs Polydorou was transferred to the Royal London Hospital where she underwent an immediate right mini craniotomy and evacuation of the acute subdural haematoma. Her recovery was extremely slow. Mrs Polydorou remained on a ventilator in the Intensive Care Unit for several weeks. During which time, she had multiple episodes of ventilator-associated pneumonia, which were treated with antibiotics. Mrs Polydorou died at the Royal London Hospital on 18 September 2017. The Homerton University Hospital has revised its procedures regarding anti-coagulation and falls as a result of Mrs Polydorou’s death. 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) Mrs Polydorou did not receive a CT scan within 8 hours of her fall because she had a Glasgow Coma Scale of 15/15, she did not have any abnormal neurological observations and was not taking Warfarin. Mrs Polydorou was concurrently taking aspirin, clopidogrel and enoxaparin during her hospital admission. All of which have the effect of thinning the blood. (2) Evidence from a consultant neurosurgeon established that there can be a significant delay in elderly patients showing signs of head injury following a fall, particularly where they are taking blood thinning medications. (3) Mrs Polydorou’s first language was Greek. Witnesses described her ability to converse in English as “basic”. Whilst in A&E, her son acted as an interpreter in order to obtain a reliable history. Following the fall, it was decided that Mrs Polydorou would have a CT scan if she showed signs of deterioration such as headache, bleeding, dizziness or vomiting. Mrs Polydorou’s son, ig was told that his mother had fallen but was not told of the symptoms that may indicate that her condition was deteriorating. During a visit on 10 July, Mrs Polydorou told her son that she had a headache but he did not realise the potential significance of this. Mrs Polydorou did not report her headache to medical staff. 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 10 May 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 | have sent a copy of my report to the following: e HHJ Mark Lucraft QC, the Chief Coroner of England and Wales e Po son of Mrs Polydorou 1am 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. SakahB Assista
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.
N i C National Institute for 10 Spring Gardens Health and Care Excellence London SW1A 2BU United Kingdom 27 March 2018 +44 (0)300 323 0140 Sarah Bourke Assistant Coroner Inner North London Poplar Coroner’s Court London E14 0AE Our ref: EH90899 Dear Ms Bourke, | write in response to your Regulation 28: Report to Prevent Future Deaths, sent on 15 March 2018, regarding the death of Mrs Georgia Polydorou. ! was very sorry to learn of Mrs Polydorou’s death. We have considered the circumstances of Mrs Polydorou’s death and the concerns you have raised, in relation to the work of NICE. Our guideline on venous thromboembolism in over 16s: reducing the risk of hospital- acquired deep vein thrombosis or pulmonary embolism (NG89) was published earlier this month (updating and replacing an earlier guideline). It covers assessing and reducing the risk of venous thromboembolism (VTE) and deep vein thrombosis (DVT) in people aged 16 and over in hospital. It includes the following new recommendation regarding the use of blood thinning agents for people acutely ill in hospital: 1.4.6 Offer pharmacological VTE prophylaxis for a minimum of 7 days to acutely ill medical patients whose risk of VTE outweighs their risk of bleeding: + Use LMWHI5] as first-line treatment. + If LMWHE] is contraindicated, use fondaparinux sodiuml6]. [2018] [5] At the time of publication (March 2018), LMWH did not have a UK marketing authorisation for use in young people under 18 for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. [6] At the time of publication (March 2018), fondaparinux sodium did not have a UK marketing authorisation for use in young people under 18 for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. www.nice.org.uk | nice@nice.org.uk Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. We note that Mrs Polydorou was prescribed aspirin, clopidogrel and enoxaparin. It’s not clear whether she was on all of these at the one time - the use of all of these blood thinning agents at once may have played a factor in the development of the sudden subdural haematoma. We also have a guideline on the assessment and early management of head injury (CG176). This guideline includes recommendations on performing CT head scans in patients on warfarin (who have no other indications for CT head scan), reflecting the available evidence. The guideline developers considered there to be limited evidence regarding patients using other antiplatelet or anticoagulant drugs within studies deriving or validating clinical decision rules for determining which patients need CT head scans - particularly, evidence in determining whether they are at increased risk of intracranial haemorrhage. The guideline developers therefore made a research recommendation on this issue. Following our considerations, we believe both guidelines appropriately reflect the available evidence and do not need to be amended at this time. Nevertheless, the issues have been logged with the NICE guideline surveillance team, and will be taken into account when the guidelines are next considered for review. Yours sincerely, Sir Andrew Dillon Chief Executive
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