Alison Jeanes

Joint Group Medical Directors’ Office 
Trust Headquarters 
Room 218, Cobbett House 
Oxford Road 
M13 9WL 

Tel:  

Email:  

9 December 2020 

Ms Alison Mutch OBE 
HM Senior Coroner 
Manchester South 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Dear Ms Mutch 

Via Email Only:   

RE: Mrs Alison Jean Shirley JEANES deceased 

I am writing on behalf of Sir Michael Deegan, Chief Executive, in response to your Regulation 
28 Report sent to Manchester University NHS Foundation Trust (“the Trust”) on 7th October 
2020.  Your report related to the death of Mrs Alison Jean Shirley Jeanes at Wythenshawe 
Hospital on 4th April 2020 and whose inquest was held on 14th September 2020.  

Wythenshawe  Hospital  is  part  of  the  Trust’s  Wythenshawe,  Trafford,  Withington  and 
Altrincham (WTWA) site. 

I understand that you concluded that Mrs Jeanes suffered an accidental death, contributed to 
by a high INR level from anticoagulation.  You concluded Mrs Jeanes’ medical cause of death 
to be: 1a) Traumatic subdural haemorrhage on a background of anticoagulation; 2) Chronic 
kidney disease, vascular dementia, aortic stenosis.   

After hearing the evidence at inquest, you have raised the following matters of concern: - 

1. The inquest heard that whilst contact was made with the Neurosurgical team at Salford
Royal Hospital on the day of her admission there was no conversation with a Doctor
from that team until the day after her admission.  As a result, there was no expert neuro
input into her care for 24 hours.  There was no evidence that there was any attempt to
chase up contact earlier.

2. Mrs  Jeanes  was  brought  into  hospital  by  ambulance  at  the  direction  of  a  GP  who
recognised  that  she  had  a  suspected  head  injury  and  was  on  warfarin.    The  GP
recognised that the NICE guidance suggests there is an 8-hour window for patients on
warfarin with a suspected head injury.  Her fall had been at 23.58 on 16th March.  The
inquest heard that she was triaged but her CT scan was not expedited and was not
reported  on  until  11.45  almost  12  hours  after  the  fall.    There  was  no  evidence  of  a
system that would fast track such cases for a CT scan.

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital •  
Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital •  
Withington Community Hospital • Community Services 

 
 
 
 3.  The inquest heard that haematology advice on the day of admission was to reduce her 
INR.    This  advice  was  reconfirmed  by  the  neurosurgeons  the  following  day.    There 
were  differences  in  the  recommendations,  and  it  was  not  entirely  clear  how  that 
difference was being managed.  In any event despite repeated attempts with Vitamin 
K Mrs Jeanes INR remained above the target.  Further advice from the haematologist 
was not sought until 26th March some 9 days after her admission.  It was unclear why 
that delay had occurred as the notes suggested it had been recognised that advice 
should have been sought previously but this had not been followed up.  There was no 
evidence  before  the  inquest  of  what  system  was  in  place  or  who  would  take 
responsibility for follow up in such a situation.  

I have sought to address each of your matters of concern in turn below: -  

1.  The inquest heard that whilst contact was made with the Neurosurgical team at 
Salford Royal Hospital on the day of her admission there was no conversation 
with a Doctor from that team until the day after her admission.  As a result, there 
was no expert neuro input into her care for 24 hours.  There was no evidence 
that there was any attempt to chase up contact earlier.  

Neurosurgical Advice from Salford Royal Hospital 
Mrs Jeanes was referred to the Neurosurgical Coordinator on 17th March 2020, and the referral 
was  followed  up  the  next  day.    We  have  liaised  with  colleagues  at  Salford  Royal  NHS 
Foundation  Trust; 

,  Chief  Officer  and  Medical  Director,  and 

,  Clinical  Director  for  Surgical  Neurosciences.    Having  looked  into  this  further,  it 
appears  that the  standard of  the  record-keeping at  Wythenshawe  Hospital  may have  been 
such that when you heard evidence at the Inquest this gave rise to an incorrect assumption 
that the Neurosurgical team took a day to provide a plan, however from review of the records 
held by Salford Royal Hospital colleagues, it appears advice was in fact provided by Salford 
Royal Hospital Neurosurgical colleagues the same day that this was requested.   

This  then  given  rise  to  an  additional  concern  around  the  standard  of  documentation  at 
Wythenshawe Hospital in Mrs Jeanes’ case.  I have addressed this point below.  

In  respect  of  the  referral  to the  Neurosurgical  team  at  Salford  Royal  Hospital  for  specialist 
advice, Mrs Jeanes was referred to Neurosurgery on 17th March 2020, at 12.55 hours, via the 
on-call Administrator, in line with usual practice.  The referral confirmed that the CT brain scan 
undertaken  at  09.17  hours  that  day  had  shown  a  tiny  focus  of  left  frontal  traumatic  sub-
arachnoid  haemorrhage  and  a  thin  right-sided  chronic  subdural  haematoma  with  minimal 
mass-effect  on  account  of  Mrs  Jeanes’  cerebral  atrophy.    The  specialists  at  Salford  Royal 
Hospital  were  advised  that  the  INR  was  being  reversed,  i.e.  with  a  view  to  reducing  Mrs 
Jeanes’  INR  level.    The  international  normalised  ratio  (INR)  is  a recommended method for 
reporting prothrombin time results for control of oral anticoagulation.  Since adoption of the 
INR  system,  it  has  been  usual  practice  to  adjust  the  dose  of  Warfarin,  or  other  Vitamin  K 
antagonist, to maintain the INR within a therapeutic range.  

The  Neurosurgical  team  at  Salford  Royal  Hospital  reverted  to  the  team  at  Wythenshawe 
Hospital the same day with a recommended plan that Mrs Jeanes’ Warfarin should be held off 
for one week, with the decision as to whether/when to re-start this anticoagulation resting with 
the  referring  team  at  Wythenshawe  Hospital,  to  be  made  after  balancing  of  the  risks  and 
benefits.    The  Neurosurgical  team  at  Salford  Royal  Hospital  recommended  local  neuro-
observation  by  the  treating  team  at  Wythenshawe  Hospital,  and  it  was  deemed  by  the 
specialists that no neurosurgical intervention was required.  
www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital •  
Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital •  
Withington Community Hospital • Community Services 

 
 
  
 
 
 
 
 
 
 
 
 
 The next day, on 18th March 2020, at 10.40 hours, the treating team at Wythenshawe Hospital 
made a further referral to the Neurosurgical specialists at Salford Royal Hospital, again via 
Salford Royal Hospital’s on-call Administrator.  At that point, Mrs Jeanes’ INR was noted to 
still be raised, at 2.4 (down from 8 on admission to Wythenshawe Hospital the previous day), 
following  three  doses  of  Vitamin  K.    The  Neurosurgical  Registrar  doctor  at  Salford  Royal 
Hospital again contacted the team at Wythenshawe Hospital the same day by telephone, with 
advice documented that it was noted that Mrs Jeanes had had three doses of Vitamin K, which 
had  brought  her  INR  down  to  2.4.    The  use  of  mechanical  prophylaxis  (such  as 
thromboembolic deterrent (TED) stockings) was recommended.  The Neurosurgical Registrar 
advised the treating team to complete 48 hours of neurological observations for Mrs Jeanes, 
and to restart her Warfarin in two weeks’ time.  The advice was that there was no need to 
rescan  Mrs  Jeanes  and  that  this  would  only  be  required  if  she  suffered  a  deterioration,  for 
instance in her motor score for diagnostic purposes.  The advice from the previous day was 
reiterated  insofar  as  Mrs  Jeanes  was  not  a  candidate  for  neurosurgical  intervention.    The 
documentation from this  call  indicates that the  local  team  at Wythenshawe Hospital  was  in 
agreement with the advice.  

The Neurosurgical team at Salford Royal Hospital was again contacted on 26th March 2020, 
as Mrs Jeanes had been re-scanned due to a slight increase in her level of confusion (her 
Glasgow Coma Score, GCS, i.e. level of consciousness, was still 14).  This scan showed a 
slight enlargement to the right-sided chronic subdural haematoma (though still with minimal 
mass effect i.e. this haematoma remained small) and a new small left-sided chronic subdural 
haematoma.  Mrs Jeanes’ INR remained elevated at 2.  The Neurosurgical team at Salford 
Royal Hospital reiterated earlier advice that Mrs Jeanes was not a candidate for neurosurgical 
intervention.  

Treatment Pathway for acute intracerebral haemorrhage 
I enclose a copy of the “Intracerebral haemorrhage: Greater Manchester care pathway and 
Neurosurgical  referral  guidelines”.    This  is  the  treatment  pathway  used  for  all  acute 
intracerebral  haemorrhage  patients  in  Greater  Manchester,  applicable  to  all  relevant  Trust 
staff/clinicians.  Whilst implemented by the Greater Manchester Stroke Operational Delivery 
Network,  the  principles  around  referral  to  neurosurgery  set  out  in  this  Standard  Operating 
Procedure are applicable to any patient presenting with an intracerebral haemorrhage, i.e. as 
with Mrs Jeanes, who had not presented following a stroke.   

This  pathway  acknowledges  that  around  10%  of  patients  suffering  an  intracerebral 
haemorrhage are taking an anticoagulant at onset, and the emphasis is that after stabilising 
the patient, reversal of anticoagulation should be the first management priority.  The pathway 
states  that  any  history  of  premorbid  anticoagulant  use  should  be  actively  sought,  scanned 
after confirmation and immediately reversed using locally agreed protocols.   

The pathway also sets out the criteria to be applied to inform decision-making around whether 
a patient should be referred acutely to the Neurosurgical Registrar on-call at Salford Royal 
Hospital.  The pathway confirms that the Neurosurgical team on-call will then decide whether 
the patient should be transferred to Neurosurgery for further care.   

The pathway sets out features that may indicate patients at high risk of deterioration in the 
hyperacute phase of an intracranial haemorrhage.  These features include a GCS score of 
less than 8, airway/respiratory compromise, a decline in GCS by more than 2 points in the last 
1-hour,  posterior  fossa  intracranial  haemorrhage  with  brainstem  signs,  and  uncontrolled 
seizures.  Mrs Jeanes did not exhibit any of these features that would have been indicators of 
her being at high risk of deterioration.  
www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital •  
Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital •  
Withington Community Hospital • Community Services 

 
 
  
 
 
 
 
 
 
 
 This  pathway  also  indicates  that  the  Physicians  and  Radiologists  at  each  hospital  must 
continue to make an assessment in each case as to whether further angiographic imaging is 
required  and  the  urgency  of  this.    For  those  patients  meeting  the  criteria  for  referral  to 
Neurosurgery, guidance may also be offered by the Neurosurgical on-call team.  The pathway 
also sets out general guidance on the need or otherwise of imaging.  

Patient Pass 
Salford Royal Hospital is in the process of implementing a system called “Patient Pass”, which 
is  designed  to  improve  communication  between  referring  hospitals  and  Salford  Royal 
Hospital’s special Neurosurgical unit.  The electronic system will, as we understand it, seek to 
speed up referrals, supporting reliability in the clinical process and therefore improving patient 
safety, and providing a full audit trail for the purpose of information governance.  Patient Pass 
will ensure there is a single accessible record of discussions which will minimise the risk of 
any issues around documentation, with a date/time-stamped referral and management plans 
being recorded in the system and available to access by the specialists at Salford Royal as 
well as the referring hospital.  Patient Pass will also support speciality-specific decision-making 
and advice given, and the accessibility of that advice by the referring hospital, and the ability 
to refer back to previous referrals for the same patient.  I understand that Patient Pass was 
due for implementation this year, however this had to be postponed as a result of the COVID-
19 pandemic, and it is now expected to be implemented in 2021.  

I hope the above provides you with assurance that the specialist Neurosurgical team at Salford 
Royal Hospital were proactively contacted for input, which was promptly provided to the local 
treating  team  at  Wythenshawe  Hospital.    I  am  deeply  sorry  that  the  evidence  you  were 
provided with at the inquest led you to believe otherwise.   

Trust Staff Preparation for Inquest 
In the event that the oral witness evidence that you heard at Inquest did not provide you with 
the full information required around these points, I confirm that in September 2020 I issued, 
via the site Medical Directors for hospitals and Managed Clinical Services across the Trust, a 
reminder  about  the  professional  expectations  of  Trust  staff  when  attending  your  Coroner’s 
Court to give evidence in respect of Trust patients.  With this, I reminded colleagues about the 
General Medical Council’s guidance on “Acting as a witness in legal proceedings”, covering 
the  expectations  of  doctors  when  giving  evidence  in  a  professional  capacity.    I  reminded 
colleagues of the obligations on staff in this regard, including the need to be fully prepared 
before attending Court to give oral evidence, with access to and familiarity with the relevant 
entries in the clinical notes in order that you are provided with all relevant evidence to assist 
your inquiry and enable you to conclude Inquests satisfactorily.  

Standard of Documentation at Wythenshawe Hospital 
I  sincerely  apologise  that  the  standard  of  documentation  in  Mrs  Jeanes’  clinical  notes  at 
Wythenshawe  Hospital,  specifically  around  the  liaison  with  the  Neurosurgical  specialists  at 
Salford Royal Hospital, appears to have been lacking in this case such that the evidence at 
inquest gave you the impression that there was no conversation with a doctor from that team 
until the day after Mrs Jeanes’ admission to hospital, when in actual fact, as set out above, 
this was not the case.  This clearly falls short of the standards that we as a Trust expect.  

The  Nursing  and  Midwifery  Council’s  “The  Code:  Professional  standards  of  practice  and 
behaviour  for  nurses,  midwives  and  nursing  associations’  (2018)  and  the  General  Medical 
Council’s  “Good  Medical  Practice”  (2013)  set  out  the  expected  professional  standards  and 
responsibilities  around  clinical  record-keeping.    All  patient-facing  staff  at  the  Trust  are  of 
course required to follow these fundamental principles.  
www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital •  
Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital •  
Withington Community Hospital • Community Services 

 
 
  
 
 
 
 
 
 
 
 In addition to this, the Trust also has its own local policy in respect of clinical record-keeping, 
which sets out the expected standards of documentation along with best practice guidelines 
relating to both paper and electronic records.   

The Trust’s separate health records management policy also emphasises that health records 
are essential for delivering quality and safety of patient care and highlights the legal obligations 
and responsibilities of individual staff members to comply with the legal requirements of health 
records legislation.  

Training is provided to all clinical staff in respect of documentation in clinical records and the 
standard of record-keeping is monitored by way of regular audits.  

2.  Mrs Jeanes was brought into hospital by ambulance at the direction of a GP who 
recognised that she had a suspected head injury and was on warfarin.  The GP 
recognised  that  the  NICE  guidance  suggests  there  is  an  8-hour  window  for 
patients on warfarin with a suspected head injury.  Her fall had been at 23.58 on 
16th  March.    The  inquest  heard  that  she  was  triaged  but  her  CT  scan  was  not 
expedited  and  was  not  reported  on  until  11.45  almost  12  hours  after  the  fall.  
There was no evidence of a system that would fast track such cases for a CT 
scan.  

Emergency Department (ED) Team 
Having reviewed the clinical notes, I confirm that Mrs Jeanes was brought to Wythenshawe 
Hospital’s Emergency Department by ambulance on 17th March 2020, accompanied by her 
carer,  following  the  fall  at  her  Care  Home.    Mrs  Jeanes  was triaged  within  the  Emergency 
Department  at  05.29  hours  as  an  “unwell/collapsed”  adult  and  was  triaged  in  the  yellow 
category, indicating she should be seen within an hour.  Mrs Jeanes’ vital signs were normal 
on admission, as was her GCS, at 15/15.  Mrs Jeanes was noted to have sustained bruising 
to the left side of her face and her carer confirmed that this was sustained from her previous 
fall on 13th March 2020 when she had previously attended the Emergency Department.  

A nursing and risk assessment were completed at 07.30 hours on 17th March 2020, i.e. just 
over two hours after Mrs Jeanes’ triage into the department.  Clearly this is outside of the one-
hour target according to her yellow triage category, and I am very sorry to note this.  At the 
time  of  this  assessment,  Mrs  Jeanes  was  scoring  1  on  her  Modified  Early  Warning  Score 
(MEWS) due to a low temperature of 35.4 degrees.  Mrs Jeanes was referred immediately to 
Wythenshawe Hospital’s Older Persons Assessment Liaison (OPAL) Unit, based adjacent to 
the Emergency Department.  Mrs Jeanes was seen by a doctor from the OPAL unit between 
08.30 and 09.00 hours.  Mrs Jeanes had bloods taken and a CT head scan was requested at 
08.32 hours.  This CT scan was completed at 09.16 hours (after the fall at 23.58 hours, which 
I note falls outside of the 8 hour target) and later reported by the Radiology team (please see 
below), showing a new intracranial bleed (compared to the previous CT scan undertaken on 
13th March 2020).  Mrs Jeanes’ INR also returned with abnormal results, at 8.3, and the OPAL 
medical team was informed.  At 10.05 hours, Emergency Department nursing documentation 
indicates  that  the  doctors  were  awaiting  the  CT  head  scan  results  and  were  to  prescribe 
Vitamin K with a view to lowering Mrs Jeanes’ INR level.  Vitamin K was given at approximately 
11.00  hours.    Mrs  Jeanes  was  transferred  from  the  Emergency  Department  to  the  Acute 
Medical Unit for further inpatient treatment.  

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital •  
Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital •  
Withington Community Hospital • Community Services 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 I am sorry to note that Mrs Jeanes was not seen as urgently as required within the Emergency 
Department.  I wonder if the category selected on Mrs Jeanes’ triage within the Emergency 
Department, of “unwell/collapsed”, as opposed to flagging the presenting history of a fall and 
potential  head  injury,  may  have  led  to  a  failure  to  recognise  the  urgency  with  which  she 
required medical review and a CT head scan.  

Emergency Department Head Injury Pathway 
I  enclose  the  recently  updated  (in  August  2020)  local  head  injury  pathway  in  place  at 
Wythenshawe  Hospital’s  Emergency  Department,  for  use  by  clinical  staff  when  assessing 
adult patients for a head injury and for documenting the assessment in the patient’s clinical 
notes.  This local pathway is in line with NICE guidance and serves to guide clinicians as to 
the steps to be undertaken to ensure a comprehensive assessment of patients presenting with 
a head injury.  The local pathway specifically covers the indications for a CT scan and/or to 
contact the Neurosurgical specialists for advice and provides the template for documenting 
the outcome of CT scan/Neurosurgical advice in the clinical notes.  This pathway also covers, 
in line with NICE guidance and as you point out, that in cases such as Mrs Jeanes’, a CT scan 
is required within 8 hours of the injury. 

I also enclose the “Clinical Decision Support Tool”, which contains a user friendly flow chart 
for use when assessing and treating adult patients presenting with head injuries, which covers 
the  requirements  around  CT  head  scans  being  undertaken  according  to  the  patient’s  risk 
category, as well as the circumstances in which advice should be sought from Salford Royal 
Hospital’s Neurosurgery team based on abnormality on the imaging.  This tool is embedded 
within the Electronic Patient Record system used by clinicians in the Emergency Department 
as decision support software.  

Radiology Team 
Radiological  imaging at Wythenshawe Hospital falls under the Managed Clinical Service of 
Clinical  and  Scientific  Services,  who  have  looked  into  this  in  respect  of  the  CT  scan  and 
reporting pathway.  Based on review of the Computer Radiology Information System (CRIS) 
it appears that the doctor on the ward submitted the request to the Radiology team at 08.32 
hours on 17th March 2020, stating, “89yo female presenting with unwitnessed fall with head 
injury on warfarin ?ICH”, i.e. given that Mrs Jeanes had presented to hospital following a fall 
at her Care Home, querying whether she may be suffering from an intracranial haemorrhage 
and requesting a CT scan for this reason.   

After the request was submitted by the ward at 08.32 hours, Mrs Jeanes attended Radiology 
and the scan was performed at 09.16 hours, i.e. within 44 minutes.  This is within the required 
Key  Performance  Indicator  (KPI)/target  for  imaging  of  this  nature,  which  requires  that  for 
patients in the Emergency Department with a head injury, the required turnaround time from 
the scan being requested to being performed should be within an hour.  The time from the 
scan being undertaken to a verified CT scan report being provided was two hours, with the 
report being verified at 11.16 hours, which the Radiology team accepts is one hour outside of 
the  required  KPI/target,  according  to  which  it  is  expected  that  CT  scans  of  this  nature 
requested by the Emergency Department are to be reported within an hour of the examination.  
The CT scan was reported by the Radiology Registrar doctor, under the supervision of the 
Consultant Radiologist.  The report included a “red alert” indicating that the finding required 
review  by the  ward team.    The  case  has  been reviewed  by the  Trust’s Clinical  Director  for 
Radiology, who notes and accepts the short delay in reporting the scan, adding that on review, 
it does not appear that this delay in reporting the scan would significantly have contributed to 
an adverse outcome for Mrs Jeanes.  

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital •  
Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital •  
Withington Community Hospital • Community Services 

 
 
  
 
 
 
 
 
 
 
 Radiology Reporting Strategy 
A  local  Trust  policy,  “Division  of  Imaging  Reporting  Strategy”,  currently  in  draft,  is  in  the 
process  of  being  finalised,  under  the  leadership  of  the  Clinical  and  Scientific  Services 
Managed  Clinical  Service.    This  policy  will  be  applicable  to  all  staff  involved  in  diagnostic 
imaging  examinations.    This  will  be  the  first  Division  of  Imaging  Reporting  Strategy  for  the 
Trust, the purpose of which is to set out the priorities, principles and ambitions for providing 
high-quality  reports  for  service  users  over the  next five  years  and, therefore,  delivering the 
Division’s vision and objectives.  This Reporting Strategy is the plan through which the Division 
of Imaging will focus on the quality and safety of reporting structures.  It will ensure that there 
are  appropriate  reporting  pathways  for  all  modalities  across  the  Division  and  there  is  a 
harmonised approach to delivering this information to clinical teams.  The Reporting Strategy 
will be applicable across all hospital sites and Managed Clinical Services Trust-wide.  

This policy defines “critical findings” and “urgent findings”, which, based on the findings/results 
in  imaging  examinations  require  immediate  or  urgent  communication  with  the  referring 
clinicians, due to the findings reflecting conditions that are life threatening or require immediate 
change of management plan, or where the interpreting clinician reasonably believes may be 
seriously adverse to the patient’s health and may not require immediate attention but, if not 
acted on, may worsen over time and possibly result in an adverse patient outcome.  

The new Reporting Strategy, once finalised and ratified, will be used in conjunction with the 
Trust policy for requesting, review and actioning of diagnostic test results at the Trust, which 
is already embedded. 

3.  The  inquest  heard  that  haematology  advice  on  the  day  of  admission  was  to 
reduce  her  INR.    This  advice  was  reconfirmed  by  the  neuro  surgeons  the 
following day.  There were differences in the recommendations, and it was not 
entirely  clear  how  that  difference  was  being  managed.    In  any  event  despite 
repeated  attempts with  Vitamin  K  Mrs  Jeanes  INR  remained  above the  target.  
Further advice from the haematologist was not sought until 26th March some 9 
days  after  her  admission.    It  was  unclear  why  that  delay  had  occurred  as  the 
notes suggested it had been recognised that advice should have been sought 
previously but this had not been followed up.  There was no evidence before the 
inquest of what system was in place or who would take responsibility for follow 
up in such a situation. 

INR Monitoring 
Mrs Jeanes’ INR was at a level of 8.3 on admission to hospital and her case was appropriately 
discussed with the on-call Haematologist who advised administering Vitamin K, 10mg, with an 
aim  of  reducing  the  INR  level  to  below  1.0.    It  was  recommended  that  Octoplex  could  be 
administered if there were any concerns arising in respect of extension of the bleed.  

Later  on  17th  March  2020,  a  repeat  INR  check  after  administration  of  Vitamin  K  remained 
elevated, at 6.3.  As documented in the clinical notes, on 18th March 2020, the Neurosurgery 
specialists at Salford Royal Hospital, at 12.20 hours on 18th March 2020, recommended an 
INR of less than 1.2 on the balance of the risks and benefits in Mrs Jeanes’ specific case.   A 
further 15mg of Vitamin K was administered on 18th March 2020.   

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital •  
Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital •  
Withington Community Hospital • Community Services 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 By 26th March 2020, noting that despite treatment with Vitamin K Mrs Jeanes’ INR remained 
at  2,  further  advice  was  obtained  from  the  Haematology  team  that  day  and  on  27th  March 
2020, and a decision was made to give Octaplex, following which INR reduced to 1.5.  Sadly 
however, Mrs Jeanes’ condition rapidly deteriorated as a result of her subdural haematoma 
and confounded by significant frailty and comorbidities.  

Guidance indicates that oral administration of Vitamin K will produce a significant fall in INR 
within 8-24 hours, and with Vitamin K administered intravenously the fall will be more rapid.  
Though  Mrs  Jeanes’  INR  level  was  brought  down,  I  note  that  it  unfortunately  remained 
elevated beyond the recommended level despite administration of Vitamin K.  

Advice from Haematology 
The requirement is that the on-call or ward team should contact the Haematology specialists 
at Wythenshawe Hospital should they require advice.  Patients should then be referred back 
to  the  Anticoagulant  Clinic  on  discharge  from  hospital  for  follow-up  care.    The  Trust  has  a 
Haematology service which is on-call 24 hours a day, 7 days a week.  The Haematology team 
will advise on appropriate reversal of anticoagulation.  It is the ward team’s responsibility to 
follow-up and action such advice, and to refer back to Haematology should further specialist 
input be needed in the course of the patient’s admission.  

Clinical/ward  teams  are  also  clearly  required  to  consider  national  guidance,  such  as  that 
provided by NICE around oral anticoagulants, and that within the BNF.  This guidance refers 
to the use of Vitamin K and specifically refers to the target INRs for adults for Warfarin and 
take into account the recommendations of the British Society for Haematology guidelines on 
oral anticoagulation with Warfarin.  The national guidance is clear on the main adverse effect 
of all oral anticoagulants being haemorrhage, and that checking the INR and omitting doses 
when appropriate is essential.  

The Trust’s locally implemented “Transfusion Policy” also provides specific guidelines for the 
management  of  Warfarin  reversal,  produced  in  conjunction  with  the  British  Committee  for 
Standards  in  Haematology  “Guidelines  on  oral  Anticoagulation  (Warfarin)”.    This  Trust 
guidance refers to patients suffering from a bleed and the appropriate doses of Vitamin K to 
be used to reverse over-anticoagulation depending on INR.  The guidance is clear that local 
ward teams should contact the Trust Haematologist if needed.  

Trust clinicians are required to follow these standards.  I am very sorry that, despite the efforts 
of the treating ward team at Wythenshawe Hospital, Mrs Jeanes’ condition deteriorated, and 
she very sadly died.  

We hope that the above provides you and Mrs Jeanes’ family with assurance in respect of the 
matters of concern you had raised.  The Trust is committed to ensuring patient safety is our 
priority.  If you require any further information, please do not hesitate to contact us.  

Yours sincerely 

Joint Group Medical Director / Responsible Officer 
GMC 

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital •  
Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital •  
Withington Community Hospital • Community Services 

 
 
  
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 CC via email only:  coronersmanchestersouth@ukemail.icasework.com  
coroners.office@stockport.gov.uk  

Enclosures: 
▪  Greater Manchester Stroke Operational Delivery Network, “Intracerebral haemorrhage: 

Greater Manchester care pathway and Neurosurgical referral guidelines”; 

▪  Wythenshawe Emergency Department, “Adult Head Injury” Pathway; 
▪  Wythenshawe Emergency Department, “Clinical Decision Support Tool, Adult Head Injury”. 

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital •  
Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital •  
Withington Community Hospital • Community Services