Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0305, written 31 Oct 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Oct 2018 |
|---|---|
| Reference | 2018-0305 |
| Deceased | Dorothy Strickley |
| Coroner | Lydia Brown |
| Coroner area | Leicester City and South Leicestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals of Leicester NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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: Mr J. Adler, Chief Executive University Hospitals of Leicester NHS Trust 1 CORONER am Lydia Brown Assistant Coroner, for the area of Leicester City and Leicestershire South 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 INVESTIGATION and INQUEST On 3~d July 2018 I commenced an investigation into the death of Dorothy Joan Strickley The Inquest concluded on 29~h October 2018 Cause of death: 1 a Pulmonary embolism 2 Laparoscopic appendectomy for appendicitis 4 CIRCUMSTANCES OF THE DEATH Mrs Strickley underwent emergency surgery on 10`" June 2018 for appendicitis. While in hospital she was provided with and wore anti embolic stockings. She was discharged home several days later, without surgical stockings which had been prescribed to her and were necessary to reduce the risk of venous thromboembolism, The stockings were not physically provided, were not mentioned in the letter of discharge and were not referred to either in the Consultant's clinical notes or the discharge nursing entries. She became short of breath at home and died 19 days after surgery from massive pulmonary embolism. She was not made aware of any warning signs or symptoms that should have led to her seeking urgent medical attention. The local Guidelines for Pharmacological and Mechanical Thromboprophylaxis for venous thromboembolism does not cover patient discharge from hospital, although the importance of continuing to wear anti embolic stockings (AES) after discharge until the normal daily activity levels are resumed is clearly set out in the NICE guidelines NG89. 5 CORONER'S CONCERNS A basic and routine prescription for AES was not successfully brought to the patient's attention at the time of discharge and Mrs Strickley was unaware of the need to continue to wear stockings until she returned to her usual daily activity level. She died from the ver com lication that the stockin s would have hel ed to revent. Various ways of communicating this to the patient were not utilized, such as the hospital discharge letter. There appeared from the evidence heard to be no standard literature or pamphlet providing patient discharge information. There was a failure of both nursing and surgical teams to ensure AES were provided and the patient and/or her family were advised of the correct use. Further training may therefore be considered necessary, together with a review of the documentation such as the nursing discharge tool. The current local policy does not reflect NICE guidelines in full. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2 January 2019 I, 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. 8 COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons. Care Quality Commission Healthcare Safety Investigation Branch 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 publicat' Coroner. f your response by the Chief 9 [DATE] 31110/2018 [SIGNED BY CORONER] ~,_,~ ~( ~~
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.
NHS' University Hospitals of Leicester NHS Trust Ca r i~j~ ~' QJ~ ~ Leicester Royal Infirmary Chief Executive's Corridor Level 3, Balmoral Building Infirmary Square Leicester LE1 5WW 21 December 2018 Mrs LC Brown Assistant Coroner Leicester City and South Leicestershire The TOWn Ha~~ Town Hall Square Leicester LE1 9BG Dear Mrs Brown Re Dorothy Joan STRICKLEY Thank you for your letter of 31St October 2018 sent following the issue of a Regulation 28 Report. I am now in a position to respond. Where it is intended that a patient such as Mrs Strickley is to be discharged with Anti-Embolic Stockings (AES) there needs to be clear communication about this issue within the clinical team caring for the patient. Regrettably this did not occur on this occasion and I am sorry that this was so. am able to confirm that the Clinical Management Group that cared for Mrs Strickley has undertaken an exercise with relevant members of the treating medical team, led to ensure appropriate reflection by the Clinical Director, on the importance of good written and verbal communication. I n addition the Trust has considered its management of VTE and has set up a Task and Finish Group which is co-chaired by our Deputy Medical Director, , and our Director of Clinical Quality, . The Task and Finish Group will consider a number of areas including those which are referred to in your Regulation 28 Report and include:- 1. Undertaking a review of current UHL Guidance and measure it against NICE recommendations. 2. Undertaking a review of written discharge information provided to patients/relatives. 3. Undertaking a review of current thromboprophylaxis practice within the Trust and measure this as against NICE Guidance. This will include the provision of AES and accompanying advice. University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary. Website: www.leicestershospitals.nhs.uk Cont'd ..... 4. Identifying the training provided for thromboprophylaxis and any further training required. 5. Undertaking a governance review and oversight of VTE arrangements within the Trust and oversight of the Trust's Thrombosis Prevention Committee. This will include a review of information given to patients on discharge. 6. Overseeing the development of a Standard Operating Procedure for use between our Emergency Department and our fracture clinic. An interim report is expected to be available by the end of January 2019 and a final report is expected to be available by the end of March 2019. I would be happy to share these reports with you. Please let me know if you would like to see them. What further actions are taken thereafter undertaken will obviously depend on the findings of the Task and Finish Group. While this work is underway we have issued a VTE Learning Bulletin to all clinical staff reiterating the Trust's Guidelines for Pharmacological and Mechanical Thromboprophylaxis for VTE and the lessons learned from this death. Through this bulletin staff were reminded of the need to ensure that in all cases where a patient requires ongoing DVT prophylaxis post-operatively and post-discharge this is documented in the patient's notes, and recorded in the patient's prescription, and that this information includes details of how long the stockings need to be worn. Medical Staff were asked to ensure that this bulletin is discussed with their teams and cascaded to all relevant juniors. This work was led by our Deputy Medical Director, Colette Marshall. trust that this provides you with the assurance that we have taken this matter very seriously. If you would like any further information please do not hesitate to contact me. Yours sincerely Chief Executive University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary. Website: www.Ieicestershospitals.nhs.uk
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