Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0020, written 15 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jan 2019 |
|---|---|
| Reference | 2019-0020 |
| Deceased | Marie Millward-Winter |
| Coroner | Rachel Galloway |
| Coroner area | Manchester City |
| Category | Care Home Health related deaths |
| Organisation named | North West Ambulance Service 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:
NORTH WEST AMBULANCE SERVICE
Copied for interest to:
Next of kin
Chief Coroner
Each Step Nursing Home
1 CORONER
I am Rachel Galloway, Assistant Coroner, for the Coroner area of Manchester
(City).
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 29 of the Coroners (Investigations) Regulations 2013.
3
INQUEST
I concluded the inquest into the death of Marie Hilda Millward Winter on 26th
September 2017 and recorded that he/she died from:
1a Intracranial haemorrhage
1b Traumatic Injury
ii. Dementia Atrial Fibrillation (on Apixaban), Hypertension.
4 CIRCUMSTANCES OF THE DEATH
Mrs Millward Winter suffered a fall in her bedroom at the Each Step Nursing home on
the morning of the 19th August 2017. It is likely that Mrs Millward Winter fell from a
standing position after getting out of bed. She sustained a head injury, which was
likely caused by her coming into contact with the bedside table during the fall. The
head trauma led to a bleed on the brain. This bleed was increased due to Apixaban
medication (which was given to Mrs Millward Winter following the fall at Each Step
Nursing Home on the 19th August 2017). She was taken by ambulance to North
Manchester General Hospital. The bleed was highlighted following CT scan and
palliative care was provided. Mrs Millward Winter passed away at North Manchester
General Hospital on the 2nd September 2017.
During the course of the inquest, I heard evidence that the care staff administered
Mrs Millward Winter’s standard morning medication at around 9 am on the 19th
1
August 2017. This medication included her regular dose of Apixaban (anticoagulant
medication) 5 mg, which was prescribed to be given twice daily. I heard evidence
that this medication was given to Mrs Millward Winter after the fall and after the
ambulance technicians in attendance advised that her morning medication was to be
given (prior to relaying her to hospital).
On hearing the evidence of the treating clinicians at Withington hospital, I concluded
that the administration of her normal dose (5 mg) of Apixaban medication, following
her fall on the 19th August 2017, contributed to Mrs Millward Winter’s death. In
particular, whilst the head injury itself had caused the bleed to occur, the evidence
from the treating clinician at Wythenshawe Hospital was that the Apixaban increased
the severity of that bleed and contributed to her death. The clinician advised that the
anticoagulant should not to have been given to Mrs Millward Winter at Each Step
Nursing home following Mrs Millward Winter’s fall on the morning of the 19th August
2017.
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 evidence was that the medication (Apixaban) was given to Mrs Millward Winter
at Each Step Nursing Home on the advice of and/or in the presence of the
Ambulance Technicians from North West Ambulance Service after she had
sustained a head injury and prior to transporting her to hospital. The concern is that
the administration of this anticoagulation medication on the morning of the 19th
August 2017, following a head injury, worsened an internal bleed and contributed to
Mrs Millward Winter’s death. It is of concern that such medication has been given
when the patient has suffered a head injury (and is at risk of an internal bleed). It is
of concern that the medication has been given on the advice of and/or in the
presence of the ambulance technicians.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and
your organisation 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 12th March 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
I have sent a copy of my report to the Chief Coroner and to Interested Persons. I
have also sent it to organisations who may find it useful or of interest.
2
I 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.
9
Signed:
Rachel Galloway
HM Assistant Coroner for
Manchester City Area
15th January 2019
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.
Our services: Emergency and urgent care Non-emergency patient transport NHS 111 North West Ambulance Service NHS Trust BY EMAIL ONLY: coroners.office@manchester.gov.uk Headquarters Mr N Meadows 4 ° Ladybridge Hall HM Senior Coroner 399 Chorley New Road Manchester City Bolton BL1 5DD 29 March 2019 Tel: 01204 498400 Dear Mr Meadows, www.nwas.nhs.uk INQUEST TOUCHING THE DEATH OF MRS MILLWARD-WINTER. | refer to the Regulation 28 Report which Assistant Coroner Galloway issued at the conclusion of the inquest touching upon the death of Marie Millward-Winter. Firstly, | know that you will share a copy of this response with Mrs Millward-Winter’s family and on behalf of the Trust | wish to express my sincere condolences. In relation to the Regulation 28 Report, | wish to draw to your attention the fact that the Trust was not notified of the inquest date, NWAS statements were read in to evidence and the Trust was not granted Interested Person status and as such was not legally represented at the hearing or in receipt of coronial disclosure. As you will be aware, pursuant to Regulation 28(3) of The Coroners (Investigations) Regulations 2013 as re-stated within the Chief Coroners Guidance No. 5, it is a pre-condition to making a report that the “coroner has considered all [emphasis added] of the documents, evidence and information and that in the opinion of the coroner is relevant to the investigation’. Whilst by this letter the Trust provides its response to the Regulation 28 Report, it takes the view that the issue of a Regulation 28 Report was premature. The Trust was not afforded the opportunity to provide additional evidence/clarification on those matters which were raised during the course of the hearing and which gave rise to the concerns alluded to within the Regulation 28 Report. The Trust considers that, in the first instance, it ought to have been given the opportunity to provide a response to any concerns by letter. If, following consideration of that letter, the Coroner still took the view that they were under a duty to issue a Regulation 28 Report, one should have been issued at that point. The Trust’s Head of Legal Services has endeavoured to speak with the crew members who attended to Mrs Millward-Winter to obtain their account of any exchange with the nursing home staff in relation to the administration of drugs, particularly Apixaban, prior to conveying her to hospital. NT stil! works at the Trust and is now a HCPC Registered Paramedic. Headquarters: Ladybridge Hall, 399 Choriey New Road, Bolton, BL1 5DD en, Chairman: Peter White ¢ YY INVESTORS 4.2 IN PEOPLE * Interim Chief Executive: Michael Forrest FCIPD Unfortunately is no longer with the Trust and we have been unable to make contact with her. Despite the passage of time recalls the incident and also the discussion that took place between him and the care home staff in relation to the administration of the patient's own medication. At no time during that discussion was the administration of anti ~ coagulant medication mentioned. He recalls that Mrs Millward-Winter was hypertensive and the staff mentioned that she had not had her routine medication. recollection is that only hypertensive medication was administered together with the patient’s own paracetamol and codeine; this administration of this medication was duly noted on the Patient Report Form (PRF). Whilst the PRF records that Mrs Millward-Winter had been prescribed blood thinners, the administration of any anti-coagulant medication is not recorded on the PRF. HEE recollection is that there was no discussion in relation to the administration of anti- coagulant medication for two reasons; firstly, Mrs Millward-Winter was being conveyed to the hospital because she had suffered a head injury and was taking blood thinning medication and secondly, advising on the administration of an anti-coagulant was outside of his scope of practice as an Emergency Medical Technician (EMT). An EMT is not a HCPC registered professional and they therefore have a limited scope of practice. EMT's are trained to recognise the signs and symptoms of a number of conditions and administer six medications to treat these conditions and it would be out of an EMT’s scope of practice to advise beyond those, including Apixaban. In an event where an EMT, or indeed any NWAS clinician, is asked a question which is outside of their scope of practice, the Trust's procedures require that senior clinical advice is sought from the Trust's 24 hour clinical support hub which is based within its control centre. An Advanced Paramedic has provided an overview in light of the Regulation 28 Report and has noted that Mrs Millward-Winter was resident in a nursing home. In their view, the nurse on duty at the unit would supersede an EMT in respect of which medication should be administered and at what point. Whilst the Trust considers that the Regulation 28 Report was issued prematurely that in no way alters the fact that the Trust takes any concerns raised in this way very seriously and | hope that [| have responded to the concerns raised and provided assurance that the Trust has appropriate protocols and procedures in place. Finally, | am aware that Regulation 28 Reports and responses are published on the Chief Coroner's website. In light of the matters discussed in this letter, namely the Trust's view that the Regulation 28 report was issued prematurely the Trust respectfully asks that in this instance, neither the Regulation 28 report nor this response are so published. Hf you have any further questions arising from the contents of this letter, please do not hesitate to contact the Trust's Legal Services Team. Michael Forrest FCIPD INTERIM CHIEF EXECUTIVE
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