Doris Ridgwell

Ms Anna Loxton 
Assistant Coroner 
HM Coroner’s Court 
Woking 
Surrey 
GU22 7AP 

By recorded delivery and email: 

6 July 2018 

Dear Ms Loxton 

Chief Executive’s Office 
St Helier Hospital 
Wrythe Lane 
Carshalton 
Surrey SM5 1AA 

Tel: 020 8296 2267 
Web: www.epsom-sthelier.nhs.uk 

Doris Ridgwell (Deceased) 
Response to Regulation 28 Report to Prevent Future Deaths 

This letter comprises the formal response of Epsom and St Helier University Hospitals NHS 
Trust ‘the Trust’ to the issues raised in the Regulation 28 Report to Prevent Future Deaths, 
dated 15 May 2018 ‘the Report’, made subsequent to the inquest into the death of Doris 
Ridgwell, which adjourned part-heard for further evidence on 15 March 2017 and concluded 
on 15 May 2018. The Trust would like to again express our deepest sympathy and 
condolences towards the family. 

Background 

Mrs Ridgwell attended Epsom Hospital on 25 February 2017 with knee pain and swelling. 
Whilst she did not display symptoms of a high International Normalised Ratio ‘INR’, the blood 
tests ordered by her treating doctor included her INR level as she was receiving warfarin 
therapy. Her INR level was found to be 8.1 which is an abnormally high level requiring 
attention. Having been noted as abnormally high, the Biomedical Scientist in the Haematology 
Department attempted to telephone the result through to Epsom Hospital Emergency 
Department, in line with the Trust’s Standard Operating Procedure. They advised him that Mrs 
Ridgwell had been transferred to the Ambulatory Care Unit ‘ACU’ awaiting discharge. Two 
attempts were made to telephone the results through to the ACU but there was no reply. The 
results were then made available on the Clinical Manager system and no further attempt was 
made to inform the ACU of this result. 

The doctor who had requested the blood tests did not note the high INR level on the Clinical 
Manager system and stated this may be because this result was released onto the system 
after the other blood tests requested had been made available and checked, and he 
overlooked reviewing this result as his working diagnosis for Mrs Ridgwell did not include a 
high INR. 

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 Mrs Ridgwell was discharged home to her daughter’s address and no healthcare 
professionals followed up her high INR. Her over-anticoagulation was only noted and treated 
on 3rd March 2017, when she was readmitted to Epsom Hospital with a large subdural 
haematoma and intraventricular bleeds which were not suitable for active treatment, and 
further blood tests revealed her INR level was 15. She deteriorated until her death on the 
morning of 4 March 2017.         

A narrative conclusion was delivered at the inquest as follows: 

‘At 10am on 4th March 2017, Mrs Ridgwell died at Epsom General Hospital. She had been 
admitted the previous day having suffered a large subdural haematoma and intraventricular 
bleed which was not suitable for active treatment. She was found to have an INR level of 15 
and this over-anticoagulation was an important causative factor in her bleeds and therefore it 
is highly likely this contributed to her death. She had attended Epsom General Hospital with 
knee swelling and pain on 25th February 2017 when her INR level was tested and found to be 
8.1. However this result was not successfully telephoned through to the ward or noted by the 
Healthcare Professionals who managed Mrs Ridgwell's care and therefore no action was 
taken to counter the high INR until her second hospital admission on 3rd March 2017.’ 

The medical cause of death was found to be: 

1a) Large subdural haematoma and intraventricular bleed 

1b) Warfarin therapy 

2) Community Acquired Pneumonia   

The Report raises the following concerns: 

1. The Trust’s Standard Operating Procedure for Telephoning of Coagulation 

Results is not sufficiently clear regarding what action should be taken by staff in 
the Blood Sciences Department to ensure abnormal coagulation results are 
made known to the treating Healthcare professionals; 

2. A new Standard Operating Procedure has been prepared, but having had sight 
of this, I do not believe this clearly outlines for Laboratory staff the steps to be 
taken in telephoning through abnormal Coagulation Results; 

3. Abnormal results are not authorised onto the Clinical Manager system to be 

viewed by Healthcare professionals by Laboratory staff until they have 
telephoned the results through to the ward, which can potentially cause a delay in 
these being available on the system; 

4.  The Discharge summaries provided to GPs following discharge from Hospital do not 
include blood tests results, meaning a potential safeguard to check these results is 
missed; 

First and Second Concerns   

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 The first Concern set out in the Report is as follows: 

‘The Trust’s Standard Operating Procedure for Telephoning of Coagulation Results 
is not sufficiently clear regarding what action should be taken by staff in the Blood 
Sciences Department to ensure abnormal coagulation results are made known to 
the treating Healthcare professionals’ 

The second concern is as follows: 

‘A new Standard Operating Procedure has been prepared, but having had sight 
of this, I do not believe this clearly outlines for Laboratory staff the steps to be 
taken in telephoning through abnormal Coagulation Results’; 

Trust response: 

The Root Cause Analysis investigation carried out following this incident identified the fact 
that the Trust’s Standard Operating Procedure for the telephoning of clinically urgent 
abnormal coagulation results was not robust enough and that the procedure required 
strengthening. As a result of the investigation the Standard Operating Procedure was revised 
to make it clear that where it is not possible to get hold of a clinician who has requested a 
blood result which has been deemed clinically urgent, this needs to be handed over to those 
working the next shift in the Blood Sciences Department in order that continuous attempts to 
contact this clinician can be made.  This strengthened the process but following the concerns 
raised at the inquest hearing we have strengthened the process even further. 

The new process for biomedical scientists who need to alert clinical staff about abnormal 
results is set out at paragraph 15 of the revised Standard Operating Procedure ‘Telephoning 
of Coagulation Results’, see below: 

Para 15.5  Obtaining contact details and communicating clinically urgent abnormal results 

In-patient / A&E: 

  Scanned image of the request form (press F7 whilst accessing record on Telepath) 
  Lab telephone lists have most ward extensions 

1.  Switchboard can assist with contacting requesting medics, bleep 
numbers, clinical teams, medical secretaries to communicate to 
requesting/relevant healthcare professional 

2.  If you have problems contacting A&E specifically - contact the Nurse in 

charge (Epsom 07975 232 344 St Helier 07812 119 011) 

If for any reason this is not possible: 

3.  The appropriate site manager should be contacted if all attempts to 

contact the clinical team or ward are unsuccessful (Bleep 884 Epsom & 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 443 St Helier).  They should be asked to locate a responsible clinician 
and request they contact Blood Sciences to discuss an abnormal result. 

Para 15.6  Telephoning results 

Identify yourself clearly 

 
  Clearly identify the patient using at least 2 identifiers (Name, DOB, Hospital / 

NHS number) 

  Give the results, if necessary explaining why you are telephoning them 
  Ask for the results to be read back to you & document (RCONF) 
 

If necessary explain that results need to be forwarded to the appropriate medic 
as soon as possible 

  Advise that Haematology Clinical staff are available to advise 24Hrs a day 
  Take the name of the person to whom you are giving the results 
  Add the comments FCA & FCA1 “For clinical advice contact the Haematology 
Clinical team (out of hours contact the On Call Haematology Consultant)” 

Para 15.7  Documenting the Telephoning of results 

It is essential that a clear record of the communication of clinically urgent abnormal results be 
made.  Good information recorded at this stage will aid any future audit or investigation. 

Using either specimen notepad or result comments record: 

  That the result was telephoned 
  The date and time it was telephoned 
  The name of the person who took the result  
  Any other relevant details 

Third Concern   

The third concern set out in the Report is as follows: 

‘Abnormal results are not authorised onto the Clinical Manager system to be 
viewed by Healthcare professionals by Laboratory staff until they have telephoned 
the results through to the ward, which can potentially cause a delay in these being 
available on the system’; 

Trust Response: 

The Standard Operating Procedure: ‘Telephoning of Coagulation Results’ has now been 
updated to include details which makes it very clear that as soon as a clinically urgent 
abnormal result is actioned by a biomedical scientist it should be released on to Clinical 
Manager).  It is worth noting that in some instances there is a real clinical need to discuss the 
abnormal result to determine the clinical significance prior to authorising to ensure a correct 
interpretation of the result. 

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 Para 15.8 In the event that a clinically urgent result cannot be telephoned 

Under most circumstances it is possible to find an appropriate person to take abnormal results. 

If, however all reasonable steps have been taken to telephone a result it is important to not 
unnecessarily delay  authorising the result so that it is available to the requesting medical team as 
soon as possible: 

  Fully document the steps taken to telephone the result using either Telepath notepad or result 

comments 

  Add the comments FCA & FCA1 “For clinical advice contact the Haematology Clinical team 

(out of hours contact the On-Call Haematology Consultant)” 

  Authorise the result in a timely manner 

  Utilise hand-over sheets / hand-over diary to record and hand over details of the patient / result 

to the next shift so that results can be telephoned later. 

Fourth Concern: 

The fourth concern set out in the Report is as follows: 

‘The Discharge summaries provided to GPs following discharge from Hospital do 
not include blood tests results, meaning a potential safeguard to check these 
results is missed’ 

Trust Response 

The possibility of including blood results from hospitals within hospital discharge summaries 
was discussed with a GP representative from the local area at the Clinical Quality Review 
Group on 24 May 2018. They did not feel they would be able to review blood results within 
patient’s discharge summaries. Moreover, it is not felt that it would be appropriate to rely on 
GP’s to act as a potential safeguard for abnormal results. Blood results taken in hospital can 
be accessed by GP’s via a computerised patient management system, Telepath. 

We have issued new guidance for all staff to make it clear that if they are made aware of a 
patient’s clinically urgent abnormal result from the Blood Sciences Department and that 
patient has left the hospital, it is the responsibility of that individual to ensure that appropriate 
action is taken. Appropriate action will be dependent on the significance of the abnormal 
result and will range from calling the patient back to hospital for urgent review to contacting 
the patient and their GP to make them aware of the abnormal result and asking them to 
arrange an appropriate outpatient appointment. 

When the Emergency Department have been unable to communicate urgent results to 
patients who have been discharged from hospital in recent months the police have been 
contacted to ask them to attend the home address of the patient to ensure that the patient is 
brought back to hospital for urgent review.    

Conclusion 

5 

 
 
 
 
 
 
 
 
 
 
 
 
 
 As a result of the inquest and the concerns raised, the Trust has reviewed its procedures and 
has: 

1.  Revised its Standard Operating Procedure ‘Telephoning Coagulation Results’ for the 

Blood Sciences Department to make it clear that : 

a) 

In the event that a biomedical scientist is unable to get hold of a relevant 
healthcare professional by telephone to communicate a clinically urgent abnormal 
blood result they should contact the appropriate Site Manager. An abnormal blood 
result should be released on to Clinical Manager as soon as possible to avoid a 
delay in communicating the result to the requesting clinician; 

b)  A biomedical scientist’s responsibility to communicate a clinically urgent  

abnormal blood result to a relevant clinician does not cease once it has been 
released on to Clinical Manager and there needs to be a telephone 
communication of the abnormal result before it can be marked as completed.  
Where it has not been possible to telephone a clinically urgent abnormal blood 
result before the end of a shift, this must be handed over to the biomedical 
scientist taking over the next shift both orally and in a written handover document 
(handover diary).     

2.  Re-issued guidance to all clinical staff to make it clear that where a clinically urgent 

abnormal blood result is communicated to them it is their responsibility to ensure that 
this is communicated to the patient and that appropriate action is taken, even when 
that patient has left the hospital.   

I hope that this letter has provided you with assurance that your concerns have been taken 
very seriously by the Trust and that our procedures and processes have been revised to 
address those concerns. 

We will share this letter with the family of Mrs Ridgwell and hope that it provides them with 
some reassurance that the Trust now has safeguards in place to ensure that abnormal results 
are communicated to the relevant clinical staff and acted upon accordingly. 

Yours sincerely, 

Daniel Elkeles 

Chief Executive Officer 
Epsom and St. Helier University Hospitals NHS Trust 

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