Edward Cowey

National Medical Director 
                                                      Skipton House 
                                                  80 London Road 
                                                               SE1 6LH 

14th January 2021 

Miss Emma Serrano, HM Assistant 
Coroner 
Coroners Court 
St Katherine’s House 
St Mary’s Wharf 
Mansfield Road 
Derby 
DE1 3TQ 

Dear Miss Serrano 

Re: Regulation 28 Report to Prevent Future Deaths – Edward Cowey 

Thank you for your Regulation 28 Report dated 14th October 2020, concerning the 
death of Edward Cowey on 28th January 2020. Firstly, I would like to express my deep 
condolences to Edward’s family.  

The  regulation  28  report  concludes  Edward  Cowey’s  death  was  a  result  of  1a) 
Subdural haematoma; II) Anticoagulation.   

Following  the  inquest,  you  raised  concerns  in  your  Regulation  28  Report  to  NHS 
England and other involved parties, regarding: 

1.  That patient electronic and paper-based transfer information is not kept on one 
database.    Edward  Coweys’  handover  notes  were  kept  on  extra  Med,  his 
neurological observations on Patient Track and the falls form on his hard copy 
notes; 

2.  Trust  local  policy  regarding  treatment  for  head  injures  is  not  consistent  with 
NICE Guidelines and doctors cannot be expected to be aware of all trust local 
policies; 

3.  Anticoagulation  guideless  do  not  cover  a  situation  where  anticoagulation  is 

being given as a preventative measure as opposed to a treatment; and 

4.  The  Trusts  local  falls  form  does  not  direct  doctors  to  the  relevant  guidance 

regarding head injuries simply asks if a CT head scans indicated 

You also suggested the following action; 

1.  You may wish to consider the NHS policy and procedures for patient transfer, 

anticoagulation and head injury. 

University Hospitals of Derby and Burton undertook a Serious Incident investigation 
into the incident, a copy of the investigation report is also included.  

                                            NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 
 
                                 
 
                                                        
 
                                                              
 
 Background 

The  patient  was  admitted  to  the  Emergency  Department  (ED)  at  the  Royal  Derby 
Hospital on 22.1.20 at 11.06am. The history was that he had been generally unwell 
with shortness of breath and not sleeping. 2 days prior to admission he had been seen 
by the renal team and his Furosemide had been stopped. He was previously known 
to the renal team with declining renal function for 5 years. 

He  had  co-morbidities  of  Angina,  Anxiety,  Asthma,  Type 2  Diabetes,  Hypertension, 
Myocardial  Infarction,  CVA  with  slight  left  sided  weakness,  Depression  and 
Pneumonia. 

After assessment in the ED he was transferred to the Medical Assessment Unit (MAU) 
at 14.48. 

The incident 

During his stay at the hospital he suffered 2 falls. The first was on 22.1.20 at 23.55. 
He was found sitting on the floor and had not sustained any serious injury apart from 
a bang to the elbow. 

The second fall was on 23.1.20 at 03.10. He was mobilising to the toilet whilst being 
assisted  by  a  Health  Care  Assistant  (HCA) at  the  time.  On  this  occasion  he  hit  his 
head on the corner of a wall sustaining a head injury. There was however no loss of 
consciousness. 

He had a medical review and was commenced on neurological observations. He did 
not have a CT scan as the criteria for CT scan under NICE guidelines was not met. 

The outcome  

The patient was transferred to ward
was asymptomatic and mobile.  

 on the 23.1.20 at 12.30pm. At that time, he 

He  was  reviewed  by  a  junior  doctor  at  16.13pm  because  he  was  complaining  of 
numbness  in  the  hands  and  weakness.  These  symptoms  were  attributed  to  his 
previous stroke. 

A  Consultant  Physician  reviewed  the  patient  at  10.30am  the  following  day,  24.1.20 
and the symptoms of left sided weakness was noted. 

The  patient  continued  to  be  independent  until  the  25.1.20  when  he  suffered  an 
unresponsive  episode.  A  CT  head  scan  confirmed  a  large  right  sided  subdural 
haemorrhage. 

A neurosurgical opinion was obtained, (from the Queens Medical Centre, Nottingham) 
which was that the patient had sustained an acute on chronic subdural haematoma 
and that he would not survive any surgical intervention. 

Sadly, the patient passed away at 18.30 on 28.1.20. 

                                            NHS England and NHS Improvement 

 
 
 The University Hospitals of Derby and Burton’s serious incident investigation into the 
incident identified the following conclusions: 

•  Even though robust measures were taken to reduce the patient’s risk of falls 
the patient declined to comply with these. The patient was assessed as having 
capacity to make his own decision. 

•  Although the first fall was treated as such there is evidence that the patient had 
not fallen from his bed to the floor as there was no sign that he had been using 
his bed at the time. 

•  He was accompanied by an HCA during the second fall.  
•  The patient had declined to use bed side toilet facilities and was walking to the 

bathroom at the time. 

•  The  patient  was  transferred  to  ward 

on  23.1.20,  whilst  the  electronic 
handover  was  updated  to  include  the  fall  the  nursing  staff  in  MAU  did  not 
contact  the  ward  to  inform  them,  therefore  some  of  the  neurological 
observations were missed. 

•  When  the  junior  doctor  assessed  the  patient  on  23.1.20  with  symptoms  of 
weakness and numbness the focus was on the previous stroke as the cause 
rather than the fall. 

•  However, had the patient had an earlier CT scan the consultants at the review 
meeting  believed  that  had  an  earlier  discussion  with  the  neurosurgeons  at 
Queens Medical Centre Nottingham taken place, the advice would have been 
to continue with observations and re-scan should he deteriorate. 
It was the opinion of the consultants at the review meeting that the deterioration 
of the patient was sudden and unpredictable. Therefore, even if the bleed had 
been  detected  earlier  and  the  patient  had  been  on  regular  neurological 
observations, the deterioration could not have been prevented and the outcome 
would have been the same. 

• 

•  Following  the  second  fall  (where  the  head  injury  occurred)  the  doctor  who 
assessed the patient did not request a CT scan. The doctor was following NICE 
guidance (which only advises a CT scan in symptomatic patients), but the Trust 
have a separate policy that all head injuries should be referred for a CT scan. 
However as already discussed, had the patient had an earlier scan the outcome 
would  have  been  unlikely  to  have  been  different  as  the  patient  deteriorated 
rapidly and unpredictably. 

•  The  patient  had  been  prescribed  anticoagulation 

to  prevent  venous 
  of 
thromboembolism.  However,  the  patient  had  been  prescribed 
Enoxaparin  whereas  the  dose  for a  patient  with  kidney  disease  should  have 
been 

. 

•  The  patient  received  3  dose  of  Enoxaparin 

  on  22.1.20,  23.1.20  and 
24.1.20. Despite being reviewed by 2 consultants on 23.1.20 and 24.1.20 this 
was not amended. 

•  A  middle  grade  doctor  noticed  the  wrong  dose  on  25.1.20  and  change  it 
accordingly. However, the medication was stopped later than day when it was 
identified that he had suffered from a subdural bleed. 
In the medical review meeting it was noted that whilst anticoagulation is a risk 
factor  for  intracranial  bleeds  following  a  head  injury,  the  medication  that  the 
patient was receiving was not  anticoagulation but prophylactic. It was further 
noted  that  there  is  no  specific  recommendation  in  the  Trusts  falls  guidelines 

• 

                                            NHS England and NHS Improvement 

 
 
 that states that VTE (venous thromboembolism) prophylaxis should be stopped 
following a head injury. Prophylactic Enoxaparin is sometimes given to patients 
with established chronic subdural haematomas but not with acute bleeds. 
•  The patient was on 12 different medications. Whilst it is likely that because of 
his various co-morbidities he required these, it is worth noting that several of 
these have the side effect of dropping blood pressure and therefore increasing 
the risk of falls. Polypharmacy ‘per sey’ increases the risk of falls in the elderly. 

Following  the  serious  incident  investigation,  it  has  resulted  in  the  following 
recommended actions by University Hospitals of Derby and Burton NHS Trust: 

•  The Trust have made changes to how the electronic records are viewed. Staffs 
are  now  advised  to  select  the  ‘my  view’  page  when  accessing  a  patient’s 
records and recording a patient’s observations post transfer. Furthermore, the 
Trust are going to explore having ‘my view’ as the default screen log on. 

•  The  Trust  have  tightened  up  their  Standard  Operating  Procedure  (SOP)  for 

ward transfer and VTE status. 

•  The  Trust  also  concludes  that  all  patients  at  risk  of  falls  should  have  a 
medication review (to edit any medication that may increase risk) and a lying 
and  standing  blood  pressure  to  look  for  postural  hypotension.  Unfortunately, 
neither of these were done. 

•  Communication has been sent out to all staff about patients over 65 years of 

age having sitting and standing blood pressure on admission. 

•  MAU are to incorporate the Head injury guidelines and falls policy as part of the 

monthly training.   

•  The Senior Sister on MAU will have a discussion with the Senior Sister on ward 
,  to  find  a  way  to  improve  communication  between  the  wards  if  such  a 

situation happens again.   

•  The senior sisters on MAU are working towards being 100% compliant with falls 

prevention training 

•  The Trust should urgently review whether its Falls proforma should:  

o  Explicitly state when a CT scan of the head should be done, rather than 

asking, “Is a CT head indicated?” 
Include a section for post-fall Neurological examination  

o 
o  A section on Anticoagulation 
o  Explicitly identify itself as a medical document, to be filed in the patient’s 

notes in chronological order 

o  The Trust Falls group to urgently discuss the present post-Fall proforma 
with regard to the points raised, and include a doctor as part of the team 
doing the review. 

•  Since this incident occurred there is now a designated doctor on 

 who 

checks all ISBAR handovers, medications and the VTE status of patients 
•  Staff on MAU will receive communication and training with regard to updating 
the  electronic  handovers  if  additions  are  made  once  patients  have  been 
referred 

•  Staff  on  Ward 

  will  receive  communication  and  training  with  regard  to 
revisiting  the  electronic  handover  for  patients  who  have  been  referred  but 
delayed in being transferred to the Ward 

                                            NHS England and NHS Improvement 

 
 
 •  Nursing staff on 

 will receive education from the senior members of 
the  team  regarding  countersigning  entries  made  by  student  nurses  into  the 
nursing and medical notes 

•  Regarding  the  use  of  anticoagulation  in  either  a  prophylactic  or  treatment 

regimen the Trust refer to NICE guidance which states the following:  

•  Dr 

,  The  Trusts  Medical  Director  (Quality  and  Safety) 
Consultant in Emergency Medicine has contacted NICE to clarify the aspect of 
the guidance that refers to patients receiving anticoagulation. NICE are clear 
that  any  patient  whether  receiving 
for 
this  guidance. 
reasons  are 
prophylactic  or 
Consequently, the Trust will be explicit about this in the UHBD guidance. The 
Trusts Medical Director has also suggested to NICE that CG176 is updated to 
reflect this advice.   

low-molecular  weight  heparin 

therapeutic 

included 

in 

•  The learning from this death with be shared at the Reg 28 National meeting so 

that lessons learnt can be disseminated to other Regions. 

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director   
NHS England and NHS Improvement  

                                            NHS England and NHS Improvement