Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0493, written 30 Oct 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Oct 2019 |
|---|---|
| Reference | 2019-0493 |
| Deceased | Annie Lloyd |
| Coroner | Zafar Siddique |
| Coroner area | Black Country |
| Category | Community health care |
| 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:
1.
2. Care Quality Commission
GP Principal, Brace Street Health centre, Walsall, WS1 3PS
1
CORONER
I am Zafar Siddique, Senior Coroner, for the coroner area of the Black Country.
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 15 April 2019, I commenced an investigation into the death of Mrs Annie Lloyd.
The investigation concluded at the end of the inquest on 19 September 2019. The
conclusion of the inquest was a short narrative conclusion of:
Mrs Lloyd was on anti-coagulation medication of warfarin. She was initially on a
level of 2.5mg. This was increased by the General Practitioner on the 4 March
2019 to 3mg. She continued to take an additional dosage of 2mg giving a total of
5mg for around 15 days. On the 6 April 2019 she was found unresponsive and
admitted to hospital after developing a subdural haematoma. It is not clear on the
evidence if the increased dosage of warfarin gave rise to the bleed or that it was a
spontaneous bleed or alternatively involved a minor traumatic event.
The cause of death was:
1a Raised Intracranial Pressure
b
Sub Dural Haematoma
4
CIRCUMSTANCES OF THE DEATH
i) Mrs Lloyd was on warfarin medication and had a medical history including
atrial fibrillation.
ii) She would attend the anti-coagulation clinic at Hospital and her last
attendance at the clinic on the 7 March 2019 confirmed she was on 2.5mg
per day. She would normally take two brown tablets (1mg) and one white
tablet (0.5mg) giving a total of 2.5mg.
iii) On the 4 March 2019, a prescription for 3mg warfarin was issued by her GP,
The GP has suggested that they were informed by family
members that she now required a dosage of 3mg.
iv) From the evidence it appears that she was then taking one blue tablet (3mg)
and two brown tablets giving a dosage of 5 mg over a period of around two
1
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weeks.
v) Mrs Lloyd started to experience chest pain and they went back to the
surgery to see the GP on the 1 April 2019. The family told the GP that she
had taken 5mg and the GP understood this to mean she had taken a single
“one-off” dosage and reduced the dosage to 2mg for a week and then for
her to recommence at 2.5mg
vi) Evidence from a Consultant Haematologist confirmed warfarin is used as
anticoagulation to prevent strokes and treat atrial fibrillation. The increased
warfarin may have caused a bleed or expansion of a bleed caused by
another event and we cannot rule out a mild trauma event; although there
was no clear evidence of a traumatic injury.
vii) On the 6 April 2019, Mrs Lloyd was found at her home unconscious. On
arrival at New Cross Hospital she was deeply comatose. A CT Scan of her
head revealed a large subdural haematoma with raised intracranial
pressure. Sadly, her condition declined rapidly, and she passed away the
same day.
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. –
1. Evidence emerged during the inquest that there was an inadequate process in
place for checking the patient’s warfarin level dosage. It appears that a “yellow
book” confirming the dosage was being copied and the GP issued the
prescription without checking this.
2. The GP practice claim to have placed reliance on the family to confirm the
dosage required.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the
power to take such action.
1. The GP Practice may wish may wish to review its processes in place in general
when dealing with prescriptions including repeat prescriptions. More specifically,
they may wish to review the process in place when changing a dosage of
warfarin.
2. The CQC may wish to further review the GP Practice and consider whether
further inspections are necessary.
2
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7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 26 December 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; Family.
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
30 October 2019
Mr Zafar Siddique
Senior Coroner
Black Country Area
3
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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.
Brace Street Health Centre 63 Brace Street Walsall WS1 3PS Mr Zafar Siddique Senior Coroner Black Country Area Dear Mr Zafar, RE: Mrs Annie Lloyd | can confirm that these are the improvements that we have implemented to prevent future deaths from occurring: 1. All of our patients (who take Warfarin) have been told that they must bring in their yellow Warfarin book every time they go to have their INR checked at the hospital. The Warfarin book will be scanned and then given to the practice manager who will code the latest INR. She will then enter on to their consultation the date the INR was taken, the result, what dose of medication they should be taking and when their next INR is due. She will then request the correct strength as per the yellow Warfarin book. The General Practitioner will also check the details before issuing the prescription. 2. We have recently undertaken safe prescribing audits on NSAIDs, Valproates and Lithium. 3. The Practice now has a written Procedure for the process of prescribing Warfarin, checking INR results and altering doses. Please find this document attached. 4. We have recently undertaken a death review audit so that we can look at the causes of a death and the factors that contributed to it. If there are any actions that could prevent future deaths we will put them into practice. 5. Our CCG pharmacist is undertaking Pincer audit regularly to ensure the safety of patients taking Warfarin. He runs a search on the practice computer and prints out a list of patients, if any, who have not had their INR checked recently and gives it to the practice manager. She will then telephone the patient and ask them to bring in their yellow Warfarin book. 6. We have already prevented future problems from happening on two occasions: Date of incident: 30" August 2019 A letter from the Cardiologist was received at the practice stating that one of our patients needed to be put on Warfarin. BE telephoned the patient and was told that he had been to the Warfarin clinic and had been started on Warfarin already, ED was unaware of this as we had not received a letter from the Warfarin clinic informing us of this EB also noticed that the patient was prescribed Diclofenac last year when he was not taking Warfarin. The patient stated that the Warfarin clinic did not tell him not to take sAlD AM orncc him that he must not take any Diclofenac, Ibuprofen, Naproxen while he is on Warfarin. | contacted the anticoagulation nurse at the Warfarin clinic who told him that the patient had been seen by them and started on Warfarin and a letter had been sent to the practice but we did not receive it. HE aso told her that they must tell all patients to take their yellow Warfarin book to their General Practitioner. Date of incident: 30" August 2019 The practice manager noticed that one of our patients had been to the Warfarin clinic twice and had his INR checked but had not brought in the yellow Warfarin book to show us. The practice manager also noticed that he had not reduced the dose of Warfarin as per the yellow book. | telephoned the Warfarin clinic and told them he had been taking 6mgs daily continually instead of reducing this to 5.75mgs daily. They advised the patient to continue to take 6mgs and for him to have his INR done sooner than planned. The practice manager informed the patient that he must bring in his yellow Warfarin book every time he attends the Warfarin clinic So we can have up to date INR readings. The patient was also advised that he must follow the Warfarin clinic instructions when told to lower or higher the dose. 7. Further actions we have taken: The receptionist will photocopy and scan the yellow book immediately and then give it to the practice manager who will code the latest INR and check the correct dose. The GP will then check it again. Our pharmacist is doing a quarterly audit to make sure we are not missing any patients. a) The assistant practice manager will check Warfarin requests when the practice manager is on leave. b) We have involved the CCG who will be sending someone from the Medicines Management Team to support the practice with high risk medication reviews. c) Discussion with Medicines Management team took place on Wednesday 4" December 2019. CCG will undertake a shared care meeting to discuss what happened. We now have a robust system in place to prevent any further recurrence of future deaths from Warfarin. Yours sincerely, bynes 20" December 2019 NE ge erence DR ANAND SINHA & DR MINAX] VERMA BRAC E STREET HEALTH CENTRE 63 BRACE STREET WALSALL STANDARD OPERATING PROCEDURE WARFARIN 29 November 2019 All patients must bring in their warfarin book every time they have their INR checked at the warfarin clinic. The receptionist must take a photocopy of the warfarin book and scan it on to their computer record straight away. The photocopy must then be given to the Practice Manager who will code their latest INR reading on to investigations. She will then add a consultation with their latest INR reading, the date of the test, what dose of medication they should be taking and the date their next INR is due. The correct dose of medication will be requested via EPS. The GP will then check the entry and issue the prescription for warfarin. Any strength of warfarin that is not currently being taken must be put in the past history. When the Practice Manager is on leave Nazia (Assistant Practice Manager) will check the warfarin. Staff must not ask the doctor to sign warfarin prescriptions during consultations. These must be done at the end of the surgery. Signed: Dr Anand Sinha MEAS RGITE Ta, PANE arg mt nntneON oe LAP oa serte ERROR MIRE SO TERRY gan "oe mm aE ST appa DN A eR ALLE, PES A EM TI TT ETE TE ETI TR I es ME NEPA LEY FANON OOS Ue he ere sap ernment EN
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