Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0259, written 30 Aug 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Aug 2018 |
|---|---|
| Reference | 2018-0259 |
| Deceased | Michael Drewell |
| Coroner | Philip Holden |
| Coroner area | West Yorkshire (Eastern) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Leeds Teaching Hospitals 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Dr Yvette Oade, Chief Medical Officer, Leeds Teaching Hospitals NHS Trust, Trust Headquarters, Beckett Street, Leeds, LS9 7TF 1 | CORONER | am Philip Holden, Assistant Coroner, for the coroner area of West Yorkshire (Eastern) 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. 3 T INVESTIGATION and INQUEST On3” January 2018 | commenced an investigation into the death of Michael John Drewell, aged 57. The investigation concluded at the end of the inquest on 22" August 2018. The conclusion of the inquest was that Mr Drewell died of a pulmonary thromboembolism. aI CIRCUMSTANCES OF THE DEATH On the 16"" November 2017 Mr Drewell fell of his bike whilst travelling to work. He attended at Leeds General Infirmary and was diagnosed with a displaced ultra capsular fracture of his right hip. He subsequently underwent surgery and his hip fracture was fixed with cannulated screws. On the 17 November 2017 his treating Consultant advised that he take Tinzaparin for six weeks to reduce the risk of Deep Vein Thrombosis. He was discharged from hospital on the 22" November 2017 and was provided with a four week prescription for Tinzaparin. That prescription was given in accordance with National Guidelines but was not for the period of time, (ie six weeks), as advised by the Consultant. The prescription ended two days prior to his death. It is not possible to say whether the ending of the prescription more than minimally contributed to his death. On the 22™ December 2017 he suffered a cardiac arrest at home. Paramedics attended but were unable to resuscitate him. He was then taken to the Leeds General Infirmary and death was pronounced at 2355 hours that day. He died of a pulmonary thromboembolism which was likely a complication of his earlier hip surgery. [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. — The treating Consultant advised that Mr Drewell, because of his height and weight, be given the anti-coagulant Tinzaparin for six weeks rather than four weeks as was usual. He recorded his advice on the handwritten records at hospital following a ward round the day after surgery. When the Junior Doctor came to prescribe Tinzaparin several days later he likely did not consult the handwritten notes and only prescribed four weeks Tinzaparin immediately before Mr Drewell’s discharge from hospital. Evidence was heard that Junior Doctors would not be expected to consult the handwritten notes when prescribing drugs in accordance with NICE Guidelines. It is of concern that the advice of a Senior Clinician was not followed and, further, that his advice was not placed upon the electronic notes. ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] 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 25" October 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 Chief Coroner and to the following Interested | 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. 30” August 2018 Philip Holden Assistant Coroner West Yorkshire (Eastern)
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.
The Leeds Teaching Hospitals Date: 22 October 2018 NHS Trust Our ref: YO/bb Mr P Holden Assistant Coroner 2¢ West Yorkshire (Eastern) Uy Coroner’s Office and Court % 71 Northgate Wakefield WF1 38S www. leedsth.nhs.uk Dear Sir UAT? jalee| uc (MQ. 22.P-\P Inquest touching the death of Michael John DREWELL i refer to your correspondence of 30th August 2018, received on 31st August regarding the inquest touching the death of Michael John Drewell and the Regulation 28 Report fo Prevent Future Deaths in respact of this case. Your letter has been forwarded on for me as Chief Medical Officer for the Trust to respond to. | can confirm that the contents of your Regulation 28 Report have been shared with the relevant staff to enable us to provide you with a comprehensive response. in your report you highlight that your matters of concern are: (1) The treating consultant advised that Mr Drewell, because of his height and weight, be given the anticoagulant Tinzaparin for six weeks rather than four weeks aS was usual. He recorded his advice on the handwritten records at hospital following a ward round the day after surgery. When the junior doctor came to prescribe Tinzaparin several days later he did not consult the handwritten notes and only prescribed four weeks Tinzaparin immediately before Mr Drewall's discharge from hospital. (2) The advice of a senior clinician was not followed and, further, that his advice was not placed upon the electronic notes. The team has considered the contents of your correspondence very carefully and the responses fo the matters of concem you have ralsed in the report are detailed below. The clinical team have advised me that Mr Drewell was a 57-year-old gentleman who fell from his bicycle whilst travelling to work on 16th November 2017. He attended Leeds General Infirmary and was diagnosed with a displaced fracture of his right hip. On the day following surgery, the orthopaedic consultant advised that Mr, Chair Dr Linda Pollard cee. Hono Chief Executive Julian Hartley ee, The Leeds Teaching Hospitals incorporating: Cs x mbes df Chapel Allerton Hospital Leeds Dental Institute Seacroft Hospital Leeds Children’s Hospital NH ee St James's University Hospital Leeds General Infirmary Wharfedale Hospital Leeds Cancer Centre bane nner rataaaal wrasa Drewell take Tinzaparin for six weeks to reduce the risk of deep vein thrombosis, He was discharged on 22nd November and was provided instead with a four week course of Tinzaperin, a prescription given in accordance with NICE guidance. On 22nd December 2017 Mr Drewell suffered a cardiac arrest at home and paramedics were unable to resuscitate him. He was pronounced dead at 23.55 that day. A post-mortem examination revealed that Mr Drewell had suffered a pulmonary embolism. The course of Tinzaparin had stopped two days prior to Mr Drewell’s collapse. At the inquest it was accepted that it was not possible to say that the ending of the prescription more than minimally contributed fo his death. The Trust provided a root cause analysis summary that concluded that the correct dose of Tinzaparin had been prescribed for a gentleman of Mr Drewell’s height and weight and that there had been no lapses in care. Tinzaparin was prescribed at discharge according to NICE guidance. The trust has therefore determined that, notwithstanding the request by an individual consultant, Tinzaparin was correctly prescribed for Mr Drewell and it is not possible to say that a longer course of the anticoagulant would have prevented his death. In your Regulation 28 Report you hightight the fact that the junior doctor did not consult the hand-written medical records before prescribing the discharge medication. | am sure that you will agree that it is impractical for junior doctors to comprehensively review the medical record in its entirety when completing the electronic discharge advice note (EDAN) and prescription. It is therefore imperative that if individual clinicians decide to prescribe ‘off protocel’ they either action this themselves personally, or leave clear unambiguous Instructions within the electronic record. This can be done in two ways; either the eMeds electronic prescribing chart can be annotated or the EDAN can be pre-populated with specific discharge advice. It is regrettable that neither of these were done on this occasion and | have written to the Clinical Directors and asked that they remind all clinicians about the importance of robust handover and communication. | can reassure you that good practice is already embedded within many clinical areas throughout the Trust. For example, Elderly Medicine patients with pelvic fractures who are being discharged to care in the community (CIC) beds have Tinzaparin continued until they are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this information is then pulled through automatically to the EDAN. In addition, our pharmacists will also add electronic notes regarding discharge medication advice following multi-disciplinary team meetings with treating clinicians. Thank you for bringing these matters to my attention. I do hope that this response has assured you that the Trust has given careful consideration to the matters of The Leeds Teaching Hospitals concern you have raised. If | can be of any further assistance pleadgigd! Abt hesitate to contact me. Kind regards. Leeds Teaching Hospitals NHS Trust Chair Dr Linda Pollard cee 01 Henou Chief Executive Julian Hartley The Leeds Teaching Hospttals Incorporating: Chapel Allerton Hospital Leeds Dental Institute Seacroft Hospital Leeds Children's Hospital St James's University Hospital Leeds General Infirmary Wharfedale Hospital Leeds Cancer Centre
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