Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0154, written 15 May 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 May 2019 |
|---|---|
| Reference | 2019-0154 |
| Deceased | Marion Prance |
| Coroner | Rachel Knight |
| Coroner area | South Wales Central |
| Category | Emergency services related deaths (2019 onwards) · Wales prevention of future deaths reports (2019 onwards) |
| 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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive, Welsh Ambulance Service Trust CORONER lam Rachel Knight, Assistant Coroner, for the coroner area of South Wales Central 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. INVESTIGATION and INQUEST On the 28" February 2018 an inquest was opened into the death of Marion Hilda Prance. The investigation concluded on the 13" May 2019. The conclusion of the inquest was narrative and read as follows: On 24th February 2018 Mrs Prance had an unwitnessed fall at Garth Olwg Care Home. In 2016 she had survived a stroke, and was thereafter prescribed Rivaroxaban as an anti-coagulant drug. During the fall, Mrs Prance suffered a head injury and was then given her morning dose of Rivaroxaban on the advice of paramedics. She was subsequently diagnosed as having a subdural haematoma at hospital, and during the day her condition suddenly deteriorated. It became clear that she had suffered a catastrophic brain bleed, which was unsurvivable. The administration of the Rivaroxaban may have contributed to the extent of the brain | bleed. 4 | CIRCUMSTANCES OF THE DEATH Mrs Prance had significant co-morbidities and was prescribed many daily medications. She self-managed her type 2 diabetes. She was living in Garth Olwg Care Home, but was of full capacity and living semi-independently. She accidentally fell over when getting off the commode in her bedroom, and banged her head as well as sustaining a clavicle fracture. Care home staff rang for an ambulance which attended promptly at around 7am. Paramedics were concerned that since there may be delays at the Royal Glamorgan Hospital, it would be sensible for Mrs Prance to eat breakfast before they took her in. Staff at the Care Home asked the paramedics whether they should administer the usual morning medications. Paramedics had sight of the Medication Administration Record for Mrs Prance which included Rivaroxaban, a fast-acting anti-coagulant drug. Notwithstanding the fact that Mrs Prance, aged 82 had fallen and banged her head, paramedics advised the nursing staff to administer all her usual medications, so as to maintain the status quo, since ‘missing medications may cause additional problems to the presenting complaint’. Paramedics had an awareness of the dangers of warfarin, and accepted in evidence that in a similar scenario with warfarin, they would have ‘held off’ administering warfarin. They were unconcerned about Rivaroxaban. In evidence, the paramedic said that he had not received any training about the dangers of Rivaroxaban. A subdural haematoma was subsequently diagnosed, and Mrs Prance had developed a catastrophic brain bleed by 6pm the same day. She died the next day. It may be that the Rivaroxaban administered at around 7:30am contributed to the extent of Mrs Prance’s brain bleed. 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. — (1} A paramedic with 40 years of experience was unaware of the dangers of administering Rivaroxaban, a blood-thinning medication to an elderly lady who had suffered a fall and banged her head; (2) The training of paramedics in relation to the dangers of bleeds in patients who have fallen and are prescribed Rivaroxaban and other similar new style anti- coagulant drugs; (3) The awareness of fast-acting anti-coagulant drugs and the implications of administering them; and (4) The awareness by paramedics that in patients with head injuries following a fall, the true extent of the head injury will not be immediately obvious, and extra caution is required. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 10" July 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 family who may find it useful or of interest. 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. 15° May 2019 SIGNED: Rape Rachel Knight Assistant 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.
Ymddiri cic LQ GIG | Breerreeeeete iiwians Cymru a \AY NHS Heer amoulance: Services Pencadlys Rhanbarthol Ambiwlans a Chanolfan Cyfathrebu Clinigo! Regional Ambulance Headquarters and Clinical Contact Centre Ty Vantage Point / Vantage Point House, Ty Coch Way, Cwmbran NP44 7HF Tel/Ffén 01633 626262 Fax/Ffacs 01633 626299 www.ambulance.wales.nhs.uk CHAIR AND CHIEF EXECUTIVE’S OFFICE Our Ref: JK/5786/DR 21 June 2019 PRIVATE & CONFIDENTIAL Rachel Knight — Assistant Coroner South West Central The Coroner's Office The Old Court House Court House Street Pontypridd CF37 1JW Dear Ms Knight Re: The Inquest in relation to Mrs Marian Prance | write in response to the Regulation 28 report that you issued to this Trust dated the 15th May 2019 following the sad death of the late Mrs Marian Prance. In the Report you raised your concerns in relation to four matters. (1) A paramedic with 40 years’ experience was unaware of the dangers of administering Rivaroxaban, a blood-thinning medication to an elderly lady who had suffered a fall and banged her head; (2) The training of paramedics in relation to the dangers of bleeds in patients who have fallen and are prescribed Rivaroxaban and other similar new style anti- coagulant drugs; (3) The awareness of fast-acting anti-coagulant drugs and the implications of administering them; and (4) | The awareness by paramedics that in patients with head injuries following a fall, the true extent of the head injury will not be immediately obvious, and extra caution is required. Caderyod/Chair - Martin Woodiord Prif WelthredwriChie! Executve: Jason Kitens Mae'r Ymddiredaloeth yn croesawu gohebisetn yn y Gymraeg neu’ Saesneg The Trust weicomes correspondance in Weish or Engistr ome tly, ‘So 78 4s" 3 Cin oid Sua! Whilst the Trust acknowledges that during the Inquest you heard verbal evidence from the paramedic who attended Mrs Prance, | would like to take the opportunity to confirm with you that during 2014 a Clinical Notice number 18 entitled, Novel Oral Anti- coagulant, was published to all clinicians. In that document anti-coagulant therapies including Rivaroxaban were referred to and advice was supplied to staff regarding their use. | attach for your reference a copy of that Clinical Notice. | attach for your reference an action plan that illustrates the actions the Trust will be taking as a direct result of the Regulation 28 Report received from you, this covers both individual learning for the paramedic who provided evidence at the Inquest, as well as organisational actions to ensure that all of our clinical staff are aware of the effects of these Novel Orai Anti-coagulant drugs. | would like to extend the offer to meet with you to discuss our response in more detail and to provide you with any further assurances you make require regarding our commitment to continuous improvement. Yours sincerely Rada Chief Executive Enc. Action Plan Clinical Bulletin
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