Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0277, written 6 Aug 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Aug 2019 |
|---|---|
| Reference | 2019-0277 |
| Deceased | Joseph Charles |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North Middlesex University Hospital 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.
Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) North London Coroners Court, 29 Wood Street, Barnet EN5 4BE Telephone 0208 447 7680 Fax 0208 447 7689 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Ministerial Correspondence and Public Enquiries Unit Department of Health and Social Care 39 Victoria Street London SW1H 0EU United Kingdom 2.Legal Department North Middlesex University Hospital, Sterling Way, London N18 1QX CORONER 1 I am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater London 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 INVESTIGATION and INQUEST On the 15th May 2019 I opened an investigation touching the death of Joseph Arthur Charles , aged 82 years old. I opened and inquest on the 24th may 2019. The inquest concluded on the 6th August 2019. The conclusion of the inquest was “ Consequences of surgery following a fall at home”, the medical case of death was 1a Pulmonary thrombo- embolism, 1b Deep vein thrombosis 1c Recent surgery (right elbow) and under paragraph 2 Ischaemic heart disease, type 2 diabetes mellitus, vhronic obstructive pulmonary disease. CIRCUMSTANCES OF THE DEATH 4 On the Eighteenth of April 2019 Joseph Arthur Charles fell at his home and was taken to hospital where he had surgery to his right elbow on the Third of May 2019. Mr Charles was discharged home on the Eleventh of May 2019 and was found unresponsive in his bed by his wife on the Fourteenth of May 2019. Had Mr Charles had surgery to his lower limb he would have fallen within the National guidelines for the prevention of DVT and pulmonary embolus but there are no such recommendations for upper limb surgery. Her Majesty’s Coroner for the Northern District of Greater London (Harrow, Brent, Barnet, Haringey and Enfield) 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows. – That although there are clear National guidelines for the prevention of DVT and pulmonary embolus but there are no such recommendations or guidance for upper limb surgery. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR 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 Tuesday 1st October 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 the following Interested Persons;- Trust Department of Health 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 6th August 2019
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.
INHS) North Middlesex University Hospital NHS Trust Legal Services Department North Middlesex University Hospital Sterling Way London N18 1QX 30 September 2019 VIA EMAIL & POST Mr Andrew Walker Senior Coroner Northern District of Greater London North London Coroner’s Court 29 Wood Street Barnet EN5 4BE Dear Mr Walker Prevention of Future Death Report — Joseph Charles We write following receipt of the Regulation 28 report issued following the conclusion of the inquest into the death of the above named. Whilst we understand that the lack of national guidelines for the prevention of DVT and pulmonary embolus following upper limb surgery is a matter for the Department of Health to address, the Trust decided to undertake a review of our local policy and procedures. We can confirm that there were no failures in the care and treatment that Mr Charles received either during or following his right elbow surgery. However, we felt it was important to ensure that, in the absence of any national guidelines, our local guidelines for prevention of DVT following upper limb surgery are robust, and improvements to ensure safety netting are made wherever possible. As a result of this review, the following actions have been carried out: Review of the Trust’s Venous Thromboembolism (VTE) prevention policy It was agreed there is no need to amend or change the present guidance, which is consistent with national guidelines for lower limb surgery and specifically mentions any major surgery over 90 minutes, which would include the elbow replacement surgery which Mr. Charles had. However, there is now an opportunity to strengthen education, training and awareness of this policy is amongst the surgical tor RMI Consuta Haematologist, is to conduct an education and awareness event at the next Orthopaedic Governance Meeting on Tuesday 1 October 2019, and in addition there will be an audit meeting to publicise the policy and guidelines updates on Tuesday 3 December 2019. All inpatient and day case surgery patients to be risk assessed on discharge In addition to the Risk Assessment for VTE, which is carried out for all patients on admission, a further risk assessment is now undertaken on surgical patients prior to discharge. This has been implemented with immediate effect. The orthopaedic team are also working with the Information Technology (IT) department in order to introduce an additional step to the electronic discharge procedure, whereby there will be a requirement to complete the VTE risk assessment summary (9 disability GG confident EMPLOYER Chair: Dr Peter Carter OBE Chief Executive: Maria Kane box in order to be able to discharge the patient. This is intended to be an additional prompt to ensure the VTE risk assessment is carried out on discharge as well as admission. The !T team is due to implement this change to the system by the end of October 2019. Publishing a VTE risk assessment template/flyer in Orthopaedics Discussions are currently being held by the hospital’s Thrombosis Group regarding the publishing of a new leaflet, which is due for Trust-wide implementation by 31 January 2020. Following approval this leaflet will be incorporated into the Orthopaedics Handbook, which is due to be revised by 28 February 2020. Review of the VTE risk assessment in theatres Although appropriate risk assessments are undertaken prior to routine surgery, our investigation revealed that the required medication(VTE prophylaxix in this case) had not always been prescribed. As such, an extra domain has been added to our local pre-operative checklist to ensure that the anaesthetists will write up thromboprophylaxis on the anaesthetic drug chart during surgery. This change in process will be discussed with the Head of Anaesthetics by 31 October 2019. Yours sincerely a Maria Kane Chief Executive ENE disability @Gi confident EMPLOYER Chair: Dr Peter Carter OBE Chief Executive: Maria Kane
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