Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0067, written 26 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Feb 2019 |
|---|---|
| Reference | 2019-0067 |
| Deceased | John Thorp |
| Coroner | Catherine Wood |
| Coroner area | West London |
| 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.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, London North West University Healthcare NHS Trust 4 CORONER | am Catherine Wood, assistant coroner, for the coroner area of West London. 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 15 February 2018 an investigation was commenced into the death of John Thorp, then aged 79. The investigation concluded at the end of the inquest on 15 February 2019. The conclusion of the inquest was natural causes, the medical cause of death being 1a) Pulmonary thromboembolism 1b) Deep vein thrombosis and 2) Right lower lobe pneumonia (recent treated Legionella pneumonia), Cardiomegaly. 4 | CIRCUMSTANCES OF THE DEATH (1) Mr. Thorp became unwell in early January 2018 and was admitted to the Acute Medical Unit at Ealing Hospital on 9'" January 2018 with a diagnosis of community acquired pneumonia. He was very unwell and underwent treatment with intravenous fluids, antibiotics and oxygen therapy. He was also commenced on Tinzaparin and prescribed TED (thrombo-embolic deterrent) stockings. On the 10" January 2018 he deteriorated and was admitted to the Intensive care unit. He was ventilated and spent over two weeks in the Intensive Care Unit where he slowly improved and he was discharged to ward 6 North on 26 January 2018. He deteriorated again on the 28 January 2018 with signs of a further chest infection which was treated appropriately with antibiotics and he went on to make a slow recovery, with his oxygen being weaned and a general improvement in his condition, such that plans for discharge were being made on 6 February 2018. In the early hours of 8 February 2018 he deteriorated and became increasingly breathless. He was appropriately escalated and seen by a junior doctor who prescribed intravenous diuretics and ordered a chest x-ray. Before the latter could be performed Mr. Thorp suffered a cardiac arrest from which he could not be resuscitated and he died on the 8 February 2018. (2 S (3 = s 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) Evidence given at the inquest by a senior nurse and Consultant indicated that only a doctor could prescribe TED stockings. There were three different prescriptions for TED stockings in the three different areas where Mr Thorp was treated. The standard ward based drug chart had a tick box in the low molecular weight heparin box on the drug chart for whether TED stockings were indicated. (2) Evidence was given at the inquest that the medical staff where inconsistent in how they prescribed TED stockings. One of Mr Thorp’s drug charts had simply a tick in the box indicating there were required but there was nowhere for nursing staff to sign if they were given. Another drug chart had a separate prescription with the stockings being written up as a regular item and nurses could fill in the prescription chart to indicate if they had been given, or if not given the reasons why not. There was evidence given that this inconsistency in the way in which medical staff prescribed the TED stockings may lead to stockings being prescribed but not given which may in turn increase the risk of thromboembolic formation. Ss 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 23" April 2019. |, 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 Persons Vir Thorp’s daughter. lam 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. 26 February 2019 [SIGNED BY Catherine Wood] CouDScEc0l
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.
SD Gr Putting patients NHS ey at the HEART London North West >= of everything we do University Healthcare NHS Trust Trust Headquarters Northwick Park Hospital Watford Road Harrow Middlesex HA1 3UJ Catherine Wood 7 Assistant Coroner iti‘ CSCOC‘*dz West London Coroner's Court 25 Bagley’s Lane www. Inwh.nhs.uk London SWE 2QA 17 April 2019 Dear Ms Wood, RE: Recommendations following the inquest of John Thorp on 15 February 2019 | write further to the conclusion into the inquest of Mr John Thorp wherein you had requested the Trust to respond Regulation 28 report you had raised at the conclusion of the inquest. The Trust had been asked to respond to the following concerns: Te Trust Headquarters: Northwick Park Hospital, Watford Road, Harrow, HA1 3U) T +44 (0)20 8864 3232 Evidence given at the inquest by a senior nurse and Consultant indicated that only a doctor could prescribe TED stockings. There were three different prescriptions for TED stockings in three different areas where Mr Thorpe was treated. The standard ward based drug chart had a tick box in the lower molecular weight heparin box of the drug chart for whether TED stockings were indicated. - Evidence was given at the inquest that the medical staff were inconsistent in how they prescribed TED stockings. One of Mr Thorpe’s drug charts had simply a tick in the box | indicating they were required but there was nowhere for nursing staff to sign if they were given, Another drug chart had a Separate prescription chart to indicate if they had been given, or if not given the reasons why not. There was evidence given that this inconsistency in the way in which medical staff prescribed the TED stockings may lead to stockings being prescribed but not given which may in turn increase the risk of thromboembolic formation. Follow us on Twitter @LNWH_NHS wow Inwh nhs.uk or lke us on Facebook al London North West Healthcare The Trust is now in a position to respond to your concerns as follows: The Trust has formulated a new, Standardised prescription chart to be used across the Trust. The new chart has a section for the prescribing of TED stockings. The Venous Thromboembolism risk assessment is on page 3 of the prescription chart. Once this is completed by the doctor, the nurses will then follow the actions required. Where the actions include the prescribing of TED stockings, this will be written on page 4 of the prescription under “Mechanical Thromboprophylaxis”. This information will be filled in on a daily basis by means of signature and date to indicate that they have checked the fitting of the stockings or devices and checked the integrity of the skin. The actions required have been shared by way of memos to all clinical staff. Junior Doctors have received the instructions via the Medical Education Department. Three separate memos were created to ensure the different clinical areas received the information to be acted upon. This information was also circulated Trust wide in the Trusts’ newsletter, The Pulse and as a Screen saver on Trust desktop computers. This has also been included as part of the Matron’s Quality Walkabout for auditing and monitoring to ensure that this section is being completed by the doctors and nurses. A copy of the new prescription chart and the memos that were circulated are enclosed as reference. We hope that the actions mentioned above are adequate in response to the concerns you have raised in your Regulation 28 Order. Yours sincerely cael Docherty BBE | ief ecutive” Trust Headquarters: wiv Inwhonhs.uk Northwick Park Hospital, Watford Road, Harrow, HA1 3U) Follow us on Twitter @LNWH_NHS T +44 (0)}20 8864 3232 or Ike us on Facebook at London North West Healthcare
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