Prevention of Future Deaths reports · 2020

Ann Smith

Regulation 28 report to prevent future deaths, reference 2020-0223, written 5 Nov 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report5 Nov 2020
Reference2020-0223
DeceasedAnn Smith
CoronerCaroline Beasley-Murray
Coroner areaEssex
CategoryHospital Death (Clinical Procedures and medical management) related deaths · Other related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. 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: 

Princess Alexandra Hospital 

1 

CORONER 

I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 

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 13 September 2019 I commenced an investigation into the death of Ann Margaret 
Smith. The investigation concluded at the end of the inquest on 3 November 2020. The 
conclusion of the inquest was that she died as a result of an accident contributed to by 
natural disease. The cause of death was 1a) subdural and intracerebral haemorrhage 
11) Hypertensive Heart Disease and Bronchopneumonia  
CIRCUMSTANCES OF THE DEATH 

The deceased was admitted to Princess Alexandra Hospital on 8 September 2019 and 
on 9 September she suffered an unwitnessed fall. She sustained a head injury and she 
died on 13 September 2019 
CORONER’S CONCERNS 

4 

5 

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.  There was uncertainty as to how to deal with the anti-coagulation aspect of 
the  deceased’s  care  in  the  wake  of  the  fall.  There  is  the  lack  of  a  local 
protocol (part of  the Falls  Policy) for  the management of  the sub-group of 
patients  over  65  on  anticoagulants  and  being  given  treatment  dose  of 
clexane for another clinical reason eg suspected pulmonary embolus, who 
sustain head trauma. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you and your 
organisation have the power to take such action.  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by the 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 –  
The 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 

5 November  2020                            Caroline Beasley-Murray senior coroner Essex 

2

Responses

2 responses 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.

Response from The Princess Alexandra Hospital NHS Trust 2 (PDF)
Hamstel Road 
Harlow 
Essex 
                                 CM20 1QX 

26th August 2021 

To Senior Coroner Lincoln Brookes 
Chelmsford Coroner’s Court 

Dear Coroner Brookes, 

Re: Ann Margaret Smith (Deceased) 

I am writing to you in my role of Medical Director at The Princess Alexandra Hospital NHS 
Trust (PAHT) regarding the inquest into the death of Mrs Ann Smith. 

This inquest was heard before Senior Coroner Beasley-Murray on 3rd November 2020. In 
conjunction with her conclusion, Ms Beasley-Murray issued a Regulation 28 report to which 
PAHT responded on 30th December 2020. Part of that response promised a subsequent 
update would be provided to the Senior Coroner by March 2021. I have now established that 
this update was unfortunately not forthcoming, primarily as a result of the overwhelming 
priorities of the Covid wave. Please accept my sincere apologies for this oversight. 

Ms Smith was admitted to Princess Alexandra Hospital on 8th September 2019. The 
following day she suffered an unwitnessed fall which resulted in a head injury and she sadly 
died on 13th September 2019. 

Senior Coroner Beasley-Murray indicated in her Regulation 28 report that she was 
concerned that ‘there was uncertainty in how to deal with the anti-coagulation aspect of Ms 
Smith’s care in the wake of her fall. That there was a lack of a local protocol for the 

management of the sub-group of patients over 65, on anticoagulants, and being given a 
treatment dose of clexane for another clinical reason, eg suspected pulmonary embolus, 
who then sustain a head trauma’. 

The importance of the patient having a clearly identified anticoagulation action plan post fall 
remains a priority for PAHT. The Action Plan developed by our multi-disciplinary 
Anticoagulation/Falls Tasking Group continues apace and I include with this letter the 
previously promised update of progress with that.     

PAHT remains committed to ensuring that all of our clinical, nursing and allied health 
professional staff are fully conversant in falls prevention and falls management. Our 
Strategic Falls Prevention Plan for 2021/22 is focussed on continued training and oversight 
to ensure preventative actions. 

 
 
 
 
 
 
 
 
 We continue to make progress with regards to overall patient falls with harm, and I am 
pleased to say that we have achieved a 10% reduction during quarter 4 of 2019-20, and also 
in each of quarters 1 & 2 of 2021. Our goal is to reduce the number by 50% by the end of 
March 2022. 

I remain confident that the Trust is on course to deliver the necessary changes required.       

Yours sincerely 

Medical Director 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Overall Aim - To address the Regulation 28 noticed served by HM Coroner for Essex (November 2020)       

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. There was uncertainty as to how to deal with the anti-coagulation aspect of the deceased’s care in the wake of the fall. There is the lack of a local protocol 
(part of the Falls Policy) for the management of the sub-group of patients over 65 on anticoagulants and being given treatment dose of clexane for another 
clinical reason e.g. suspected pulmonary embolus, who sustain head trauma.                                                                                                                                                                                 

Goal 

Actions 

Establish a task and finish group comprising:   
Associate Medical Director for the Medicine 
Healthcare group.                                                         
Anticoagulation pharmacist.                                          
Lead Nurse for Falls Prevention                     

1. To establish 
a task and 
finish group to 
review the 
current 
protocols and 
make 
necessary 
changes 

By 
When 
Nov-
20 

By Whom 

Progress 

Measures of success 

RAG 

Lead Nurse 
for Falls 
Prevention                    

Group has been established   Group has been established 

 
  
 Review of the falls prevention policy 

Feb-
21 

Task and 
finish group 

2. To review  
the current falls 
prevention 
policy and to 
provide an 
update to 
include the 
management 
of this sub 
group of 
patients. This 
will include the 
quick reference 
guides on post 
falls 
management 
that are 
included in the 
appendices of  
the policy 

Fully updated falls prevention 
policy and  quick reference 
guides available in all clinical 
areas. The policy and quick 
reference guides will be fully 
updated by the end of 
January 2021for submission 
to the Patient Safety Group 
meeting and Trust policy 
group meeting in February 
2021 

The policy and quick 
reference guides have been 
reviewed. There needs to a 
section added to the policy  
relating to this sub-group of 
patients with regard to: 
anticoagulation plan - post 
fall to STOP or CONTINUE 
anticoagulation therapy.  
Frequency and duration of 
observations, including 
neuro-observations. Update 
March 21. Updated policy 
and quick reference guides 
have been distributed to all 
in-patient areas. These have 
been shared widely with ward 
teams, matrons, HoNs 
ADoNs, AHP staff, junior 
medical staff and 
consultants. Information is to 
be shared at ward huddles, 
handovers, ward meetings, 
PS&Q meetings. Changes 
have been approved by the 
Clinical Cell and Trust policy 
group. Changes to be 
included on junior doctor 
anticoagulation training and 
will be added to the Trust 
anticoagulation guidelines. 
Internal safety bulletin has 
been issued. E mail sent to 
all junior doctors and all 
consultants. 

 
  
 Task and 
finish group 

3. For each 
patient in this 
sub-group  to 
have a clearly 
documented 
Anticoagulation 
plan. 

Feb-
21 

To ensure that this sub-group of patients has a clearly 
identified anticoagulation action plan post fall. A 
medical decision needs to be made regarding STOP 
or CONTINUE anticoagulation therapy post fall and 
this must be clearly documented in the patient's 
clinical record. If the anticoagulation therapy is to be 
stopped then the prescription MUST be suspended on 
the EPMA system.  This will need to be formally 
agreed by the Senior Management Team.                                      
Senior Practitioners Forum.                                     
Clinical Cell.                                                                   
This policy will be added to all anticoagulation 
guidelines 

Fully updated falls prevention 
policy and  quick reference 
guides available in all clinical 
areas. ALL clinical staff to be 
made aware that this is a 
mandatory requirement. This 
will be achieved  by training 
and also the issuing of an 
Internal Safety Bulletin (March 
2021) etc. For this policy to be 
added to all anticoagulation 
guidelines 

The policy and quick 
reference guides have been 
reviewed. There needs to a 
section added to the policy  
relating to this sub-group of 
patients with regard to: 
anticoagulation plan - post 
fall to STOP or CONTINUE 
anticoagulation therapy.                 
This action was approved at 
the Clinical Cell meeting 
December 2020.                                        
This is to be formally 
discussed at the 
anticoagulation meeting in 
January 2021.                          
The Haematology teams 
have been asked to provide 
formal feedback on this 
change to the policy. 
25.01.21 - Feedback has 
been received and added to 
revised policy. Update March 
21 - see above (section 2) 

 
  
 4a. For the 
timing, 
frequency and 
completion  of 
observations 
(including 
neurological 
observations) 
to be 
mandatory 

The timing and frequency of observations (including 
neurological observations) is currently clearly 
identified on the post fall quick reference guides. This 
requirement needs to be clearly referenced on all 
clinical staff training sessions (see point 5 below).   In 
addition to formal training sessions this change to 
practice will be shared with the Patient Safety and 
Quality Leads for dissemination across the healthcare 
groups with the expectation that it will also be 
discussed at patient safety huddles on a daily basis 
(for 2 weeks) and then weekly (for 4 weeks 
commencing in January 2021                              

Feb-
21 

Task and 
finish group      

The policy and quick 
reference guides have been 
reviewed 

Fully updated falls prevention 
policy and  quick reference 
guides available in all clinical 
areas. ALL clinical staff to be 
made aware that this is a 
mandatory requirement. This 
will be achieved  by training 
and also the issuing of an 
Internal Safety Bulletin. 
Issued March 2021           

Nerve Centre needs to be amended to ensure that the 
completion of all sections of neurological observations 
are mandatory 

Jan-
21 

Lead for 
Clinical 
Information 
systems     

The update to Nerve Centre 
has been agreed.  The aim is 
for this to be "live" week 
commencing 18th January 
2021 

Update to Nerve Centre.      
25.01.21 This amendment 
has now been completed and 
has been communicated to all 
ward managers and matrons 

4b. For an 
update to be 
made to Nerve 
Centre to 
ensure that 
completion of 
all parts of 
neurological 
observations 
are mandatory 

 
  
  
 5. For all of the 
above actions 
to be included 
in mandatory 
falls prevention 
and 
management 
training for all 
clinical staff 

6. Mandatory 
question to be 
added to the 
Datix incident 
management 
system as to 
whether patient 
who has fallen 
is on 
anticoagulant 
therapy  
7. Trust 
strategic 
Quality 
Improvement 
Plan 

8. Corporate 
risk register 

Falls training to be made mandatory for all clinical 
staff and for the above actions to be part of this 
training. This policy is also to be added to the training 
provided by the anticoagulation pharmacists. 

Feb-
21 

For clinical staff to be up to 
date with mandatory falls 
prevention and management 
training 

Lead Nurse 
for Falls 
Prevention                    

The process to make falls 
prevention and management 
training mandatory for all 
clinical staff has begun. All 
training packages (face to 
face and e learning) will be 
amended to include the 
above actions).  Current face 
to face sessions provided by 
the Lead Nurse for Falls 
Prevention includes 
discussion on anticoagulation 
and the requirement for the 
completion of neurological 
observations 

Datix to be amended to include this question 

Feb-
21 

Lead Nurse 
for Falls 
Prevention                    

02.02.21 Mandatory question 
now added to  Datix .  

Complete 

Action to be formally added to the Trust's Strategic 
Quality Improvement Programme 

Feb-
21 

Now formally  added to QIP 

Complete 

Associate 
Director for 
Quality 
Governance  

Risk to be added to Corporate Risk Register 

Feb-
21 

Lead Nurse 
for Falls 
Prevention                    

Formal risk assessment has 
been completed. Pending 
approval from Deputy 
Director of Nursing. Once 
approved - will be added to 
Corporate Nursing Risk 
Register until corporate risk 
register is established 

Complete
Response from The Princess Alexandra Hospital NHS Trust (PDF)
Private and Confidential 

Senior Coroner Caroline Beasley-Murray 
Essex Coroner’s Court 
Chelmsford County Hall 
Victoria Road 
Chelmsford 
CM1 1QH 

Dear Coroner Beasley-Murray, 

        30th December 2020 

I write in the matter of the late Ann Smith in response to your recent Regulation 28 Report to 
prevent future deaths. 

Ms Smith was admitted to Princess Alexandra Hospital on 8 th September 2019. On 9th 
September she suffered an unwitnessed fall which resulted in a head injury. She sadly died 
on 13th September 2019 and your inquest into her death was held on 3rd November 2020. 

You were concerned that ‘there was uncertainty in how to deal with the anti-coagulation 
aspect of Ms Smith’s care in the wake of her fall. That there was a lack of a local protocol for 
the management of the sub-group of patients over 65, on anticoagulants, and being given a 
treatment dose of clexane for another clinical reason, eg suspected pulmonary embolus, 
who then sustain a head trauma’. 

The speed at which action is taken following a fall is clearly significant, as is the importance 
of the patient having a clearly identified anticoagulation action plan post fall. To that end, the 
Trust has established a multi-disciplinary Anticoagulation/Falls Tasking Group comprising of 
the Associate Medical Director for the Medicine Healthcare group, the Anticoagulation 
Pharmacist and the Lead Nurse for Falls Prevention.  

This group has developed an Action Plan, a copy of which I share with you. Whilst the 
actions from this plan are still ongoing, I am confident that the Trust is on course to deliver 
the necessary changes to ensure that there are no further severe harms or deaths from thi s 
type of incident. I propose to update you again by the end of March 2021.   

Yours sincerely 

Director of Nursing, Midwifery & Allied Health Professionals 

 
 
 
 
 
 
 
 
 
 
 
 
 Action  Plan 

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. There was uncertainty  as to how  to deal with  the anti-coagulation  aspect of the deceased’s care in the wake of the fall.  There is 
the lack of a local  protocol  (part of the Falls Policy)  for the management  of the sub-group of patients  over 65 on anticoagulants  and 
being given treatment  dose of clexane for another  clinical  reason e.g. suspected pulmonary embolus, who  sustain  head trauma.                                                                                                     

Goal 

Actions 

By Whom 

Progress 

Lead Nurse 
for Falls 
Prevention                     

Group has been 
established   

Measures of 
success 
Group has been 
established 

Status 

Complete   

By 
When 
Nov-20 

Establish  a task group 
comprising:    Associate 
Medical Director  for 
the Medicine 
Healthcare  group.                                                         
Anticoagulation 
pharmacist.                                          
Lead Nurse for Falls 
Prevention                      

1. To establish  a 
task group to 
review the current 
protocols  and 
make necessary 
changes 

2. To review  the 
current falls 
prevention  policy 
and to provide an 
update  to include 
the management 
of this sub group 
of patients.  This 
will  include  the 
quick reference 
guides on post  falls 
management that 
are included  in the 
appendices  of  the 
policy 

Review of the  falls 
prevention  policy 

Dec-20 

Task group 

 On-going 

Fully updated  falls 
prevention  policy 
and updated  and 
updated  quick 
reference guides 
updated  and 
available  in all 
clinical  areas. The 
policy  and quick 
reference guides 
will  be fully 
updated  by the 
end of January 
2021for 
submission  to the 
Patient  Safety 
Group meeting 

The policy and 
quick reference 
guides have been 
reviewed. There 
needs to a section 
added to the 
policy   relating to 
this  sub-group of 
patients  with 
regard to: 
anticoagulation 
plan - post fall to 
STOP or 
CONTINUE 
anticoagulation 
therapy.  
Frequency and 
duration  of 
observations, 
including  neuro-
observations. 

 
 
 
 
 
 3. For each patient 
in this  sub-group  
to have a clearly 
documented 
Anticoagulation 
plan. 

4a. For the timing, 
frequency and 
completion   of 
observations 
(including 
neurological 
observations)  to 
be mandatory 

Task group 

Jan-21 

To ensure that  this 
sub-group of patients 
has a clearly identified 
anticoagulation  action 
plan post  fall. A 
medical  decision 
needs to be made 
regarding STOP or 
CONTINUE 
anticoagulation 
therapy post fall and 
this  must be clearly 
documented  in the 
patient's  clinical 
record. If the 
anticoagulation 
therapy is to  be 
stopped  then  the 
prescription  MUST be 
suspended  on the 
EPMA system.  This 
will  need to be 
formally agreed by the 
Senior Management 
Team.                                      
Senior Practitioners 
Forum.                                     
Clinical  Cell.                                                                   
This policy  will  be 
added to all 
anticoagulation 
guidelines 

 On-going 

Fully updated  falls 
prevention  policy 
and updated  and 
updated  quick 
reference guides 
updated  and 
available  in all 
clinical  areas. ALL 
clinical  staff to be 
made aware that 
this  is a mandatory 
requirement. This 
will  be achieved  
by training  and 
also the issuing  of 
an Internal Safety 
Bulletin.          For 
this  policy to be 
added to all 
anticoagulation 
guidelines 

The policy and 
quick reference 
guides have been 
reviewed. There 
needs to a section 
added to the 
policy   relating to 
this  sub-group of 
patients  with 
regard to: 
anticoagulation 
plan - post fall to 
STOP or 
CONTINUE 
anticoagulation 
therapy.                 
This action  was 
approved at the 
Clinical  Cell 
meeting December 
2020.                                        
This is to be 
formally discussed 
at the 
anticoagulation 
meeting in  January 
2021.                          
The Haematology 
teams have been 
asked to provide 
formal feedback 
on this  change to 
the policy. 

Task group        The policy and 

quick reference 
guides have been 
reviewed 

 On-going 

Fully updated  falls 
prevention  policy 
and updated  and 
updated  quick 
reference guides 
updated  and 
available  in all 
clinical  areas. ALL 
clinical  staff to be 
made aware that 
this  is a mandatory 
requirement. This 
will  be achieved  
by training  and 
also the issuing  of 
an Internal Safety 
Bulletin.            

Jan-21 

The timing and 
frequency of 
observations 
(including  neurological 
observations)  is 
currently clearly 
identified  on the  post 
fall quick  reference 
guides. This 
requirement  needs to 
be clearly referenced 
on all clinical  staff 
training  sessions (see 
point  5 below).   In 
addition  to formal 
training  sessions this 
change to practice will 
be shared with  the 
Patient  Safety and 
Quality  Leads for 
dissemination  across 
the healthcare  groups 
with  the expectation 
that it  will  also be 
discussed  at patient 
safety huddles  on a 
daily basis (for 2 
weeks) and then 
weekly (for 4 weeks 
commencing  in 
January 2021                             

 
 4b. For an update 
to be made to 
Nerve Centre 
software to ensure 
that completion  of 
all parts of 
neurological 
observations  are 
mandatory 

Nerve Centre needs to 
be amended to ensure 
that the  completion  of 
all sections  of 
neurological 
observations  are 
mandatory 

Jan-21 

Lead for 
Clinical 
Information 
systems     

The update to 
Nerve Centre has 
been agreed.  The 
aim is for this to 
be "live" week 
commencing  18th 
January 2021 

Update to Nerve 
Centre software 

 On-going 

Feb-21 

5. For all of the 
above actions  to 
be included  in 
mandatory falls 
prevention  and 
management 
training  for all 
clinical  staff 

Falls training to be 
made mandatory for 
all clinical  staff and for 
the above actions  to 
be part of this 
training. This policy  is 
also to be added to 
the training  provided 
by the anticoagulation 
pharmacists. 

 On-going 

For clinical  staff to 
be up to date with 
mandatory falls 
prevention  and 
management 
training 

Lead Nurse 
for Falls 
Prevention                     

The process to 
make falls 
prevention  and 
management 
training 
mandatory for all 
clinical  staff has 
begun. All training 
packages (face to 
face and e 
learning) will  be 
amended to 
include  the  above 
actions).   Current 
face to face 
sessions provided 
by the Lead Nurse 
for Falls 
Prevention 
includes  discussion 
on anticoagulation 
and the 
requirement  for 
the completion  of 
neurological 
observations

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