Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0331, written 1 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 | 1 Oct 2018 |
|---|---|
| Reference | 2018-0331 |
| Deceased | Michael Hopkins |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Bradford Teaching Hospitals NHS Foundation 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.
IN THE WEST YORKSHIRE WESTERN CORONER’S COURT IN THE MATTER OF: The Inquests Touching the Death of Michael Christopher Hopkins A Regulation Report — Action to Prevent Future Deaths — THIS REPORT IS BEING SENT TO: Bradford Teaching Hospitals NHS Foundation Trust 1 | CORONER '| Martin Fleming HM Senior Coroner for West Yorkshire Western | 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 20 of the Coroners (Investigations) Regulations 2013 3 | INVESTIGATION and INQUEST ; On 14/6/17 I opened an inquest into the death of Michael Christopher Hopkins who, at the date of his death was aged 55 years old. The inquest was resumed and concluded on 24/9/18 -| [found that the cause of death to be: - ‘) la. Pulmonary Thromboembolism .| Ib Fracture of Right Patella (operated 13/5/17) I concluded with a narrative conclusion as follows: On 9/5/17 Michael Christopher Hopkins had an unwitnessed fall in the ‘garden of his home address. When taken to Bradford Royal Infirmary, an x-ray indicated that he had sustained a multi-fragmentary fracture of. his right patella, which required surgery to correct on 13/5/17, which went | without event, and he was discharged on 16/5/17.. Subsequently, on 9/6/17, he collapsed at his home address with difficulties breathing, but notwithstanding the attempts of paramedics to resuscitate him, he died | | from a pulmonary thromboembolism, a known complication of his |__| surgery of 13/5/17. - *“ RT3589 1 4 | CIRCUMSTANCES OF THE DEATH At approximately 4.15pm on 9/6/17 Mr Hopkins had an unwitnessed fall in the garden of his home address. When taken to Bradford Royal Infirmary he was found to have sustained a multi fragmentary fracture of his right patella. Surgery to correct it was carried out on 13/5/17 to correct it, which went without event and he was discharged on 16/5/17. Thereafter post operatively Mr Hopkins struggled with his mobility and complained of pain in his lower ankle and upper thigh. Given the severity of the pain Mr Hopkins visited his GP on 8/5/17 since he thought it was an infection of his wound. After examination the GP confirmed that his wound was not infected and it was dressed. The next day of 9/6/17 he suffered his collapse and died at his home address. CORONER’ CONCERNS The MATTER OF CONCERN is as follows. — e To review current practice guidelines with respect to the information provided to patients on discharge from hospital that may be at risk of the formation of thromboembolisms given they - have had recent surgery after sustaining a trauma. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that Bradford Teaching Hospitals NHS Foundation-Trust are in a position to take such action. . (ies SR 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. ; RT3589 2 COPIES | Thaye sent a copy of this report to: - wife of Mr Hopkins | Orthopaedic Surgeon — — Inquest Manager Chief Coroner . DATED this 1/10/18 M. D. Fleming - Senior Coroner fA D (West Yorkshire —- Western) © RT3589 3
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 Bradford Teaching Hospitals NHS Foundation Trust Our Ref: CLK/hih Clive Kay Chief Executive : Trust Headquarters 27" November 2018 Chestnut House Mr M.D. Fleming pe Senior Coroner uc ane West Yorkshire — Western Bradford BD9 6RJ City Courts Tel: 01274 382043 The Tyris BD1 1LA Dear Mr Hem | am writing in response to your letter of 2" October 2018, in relation fo the inquest, which touched the death of Michael Christopher Hopkins. In your letter, you requested a response in relation to the ‘Regulation Report-Action to Prevent Future Deaths’. , The Foundation Trust has been working hard to ensure that all eligible patients receive an assessment of their risk of developing blood clots, and can demonstrate consistent compliance with the relevant key performance indicators. Since the Regulation Report was received, we have reviewed the information provided to ail patients (not just those who have experienced a trauma), following that assessment of risk, and as a result, the Trust has developed a revised leaflet that all patients will receive. | have attached an example of the leaflet to this letter, and confirm this leaflet will be introduced from the 1*t December 2018. Our Quality Committee has asked for further assurance at a future meeting in relation to the consistency with which the leaflet is used (for instance the verbal advice which is given), and also its impact on the patients who receive it. We are, as a Foundation Trust, committed to learning from incidents where there were modifiable or preventable factors, and | believe that the summary of our response demonstrates this commitment. Yours sincerely ‘Clive Kay Chief Executive Professor Clive Kay Professor Bill McCarthy Chief Executive Chairman
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