Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0323, written 27 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Sep 2018 |
|---|---|
| Reference | 2018-0323 |
| Deceased | Mary Ryder |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health CORONER | am Alison Mutch ,Senior Coroner, for the coroner area of South Manchester 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 21% August 2017 | commenced an investigation into the death of Mary Barbara Ryder. The investigation concluded on the 26" September2018 and the conclusion was one of short narrative-Died from | a pulmonary embolism - a recognised complication of necessary cancer | surgery diagnosed on admission to Tameside General Hospital and exacerbated by an infection of her surgical wound. The medica! cause of death was 1a Pulmonary embolism 1bSurgery for bladder cancer Il Resection of bladder cancer | 4 | Mary Barbara Ryder was diagnosed with bladder cancer. She underwent surgery on 10th July 2017 at Stepping Hill Hospital. Post-operatively she was given Clexane for 28 days. She was discharged on 27th July 2017. She self-administered Clexane for the remaining period of 10 days. Further Clexane was not prescribed. Her mobility remained decreased. There was no further clinical review regarding Clexane. Her wound was large and was treated in the community by the District Nursing Team in accordance with the Tissue Viability Service Plan. On 18th August 2017 she saw the surgical consultant. He referred her for an out-patient CTPA. NICE guidance states that in such a situation, a D-dimer should be obtained - one was not done. Her would was clean and heaithy and she returned home. On 19th August 2017 her health deteriorated significantly. On 20th August 2017 she had pronounced chest pains and was admitted to Tameside General Hospital. It was identified that her wound was infected. Antibiotics were given. Her D-dimer was very high and a pulmonary embolism was diagnosed. Anticoagulation was given. She deteriorated rapidly on the evening of 20th August 2017. She died on 21st August 2017 at Tameside General Hospital. : CORONER'S CONCERNS During the course of the inquest, the evidence revealed matters giving tise 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 inquest heard that: The guidance nationally is to prescribe clexane for 28 days after an operation. However, the guidance does not suggest that some cases may require longer where a patients mobility remains reduced. There does not appear to be an emphasis on the need to review the situation throughout the post-operative period after a discharge home. 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 22nd November 2018. |, the coroner, may extend the period. nN 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 Persons —_ ae of Mary Ryder, who may find it useful or of interest. | 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. Alison Mutch OBE HM Senior Coroner 27.09.2018
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.
ay From Caroline Dinenage MP- D ep artm ent Minister of State for Care of Health & 39 Victoria Street Social Care SWiK OEU 020 7210 4850 Your Ref: 8041/CH PFD-1151078 Ms Alison Patricia Mutch HM Coroner's Court 1 Mount Tabor Street Stockport SK] 3AG Reor as (dude, Thank you for your correspondence of 27 September to Matt Hancock about the death of Ms Mary Barbara Ryder. I am replying as Minister with responsibility for patient safety and hospital care quality. 14% Nov 2018 Firstly, I would like to say how saddened I was to read of the circumstances surrounding Ms Mary Ryder’s death. If you have the opportunity, please pass on my sincerest condolences to Ms Ryder’s family and loved ones. My officials have made enquiries with the National Institute for Health and Care Excellence (NICE) on the matter of concern you have raised. I am advised that NICE has considered carefully the concern raised but does not find that its guidelines require amendment. I hope this reply will explain NICE’s position. NICE’s guideline on ‘Venous thromboembolism (VTE) in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism”, NG89 published in March 2018, includes a section on abdominal surgery that recommends to consider extending pharmacological VTE prophylaxis (which may be low molecular weight heparin (LMWH, such as Clexane) or fondaparinux sodium) to 28 days postoperatively for people who have had major cancer surgery in the abdomen. 1.14.3 Add pharmacological VTE prophylaxis for a minimum of 7 days for people undergoing abdominal surgery whose risk of VTE outweighs their risk of bleeding, 1 https: www.nice,org.uk/puidance ng89 taking into account individual patient factors and according to clinical judgement. Choose either: 0 LMWH[4jor * — fondaparinux sodium[ 5]. [2018] 1.14.4 Consider extending pharmacological VTE prophylaxis to 28 days postoperatively for people who have had major cancer surgery in the abdomen. [2018] Tam further advised that this guideline also says that all medical, surgical and trauma patients at risk of VTE (that is, deep vein thrombosis (DVT) and pulmonary embolism (PE)) and bleeding should be reassessed at the point of consultant review or if their clinical condition changes (Recommendation 1.1.8). In addition, NICE has published a guideline on ‘Venous thromboembolic diseases: diagnosis, management and thrombophilia testing", CG144, last updated in 2015, which includes recommendations on investigating for possible PE and on when to offer a D-dimer test and computed tomography pulmonary angiogram (CTPA). The guideline recommends offering a D-dimer test in patients in whom PE is suspected and with an unlikely two-level PE Wells score (clinica! prediction rule for estimating the probability of DVT and PE ~ see Recommendation 1.1.10 and table 2 of the guideline). The guideline goes on to recommend that patients with active cancer and confirmed proximal DVT or PE should be offered LMWH, and to continue the LMWH for six months. At six months, the risks and benefits of continuing anticoagulation should then be assessed (Recommendation 1.2.2). Based on the information available, NICE’s assessment is that the guidelines make appropriate recommendations on this topic, and do not need to be amended at this time. [ hope this reply is helpful. Thank you for bringing these concerns to our attention. CAAA ite ai = 1 hitng:l/www nice, org ul/guidance’ ‘www, nice.org.uk/guidance-cg144
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