Peter Unsworth

From: 
Sent: 25 January 2021 16:57 
To: 
Subject: RE: Regulation 28 Report - Mr Peter James Michael UNSWORTH 

Dear 

, 

I am writing to confirm the action that the General Medical Council has taken in 
response to HM Assistant Coroner Caroline Topping’s Regulation 28 report into the 
death of Mr Peter James Michael Unsworth.  

Upon receipt of the report the GMC’s Triage team has worked with our local 
Employer Liaison Service to obtain further information in relation to the incident and 
doctor’s involved. This resulted in obtaining the local investigation report into the 
incident from Ashford and St Peter’s Hospital.  

We have now reviewed the local report and have taken the following actions in 
relation to the two doctors involved: 

1.  Dr 

 – GMC Reference 

We note that Dr 
 requested specialist advice from a Consultant 
Haematologist which was provided over the telephone. As a result of Dr 
interpretation of the advice provided to him he reduced the patient’s dose of 
clexane. The conversation with the Haematologist was not added to the clinical 
notes and a letter confirming the decision to reduce the dose was not sent for a 
month after the conversation happened.  

Sadly after this reduction the patient went on to suffer pulmonary emboli which 
occluded his pulmonary arteries causing him to pass away on 29 July 2018.  

After review the GMC’s Triage team have decided that further enquiries are required 
into the allegations against Dr 
been opened which will allow the GMC to obtain copies of Mr Unsworth’s clinical 
records and an independent clinical opinion. The clinical opinion will address whether 
there are any fitness to practise concerns about the actions of Dr 

. As a result a provisional enquiry has now 

.  

 in 
We will attempt to complete our initial review into the actions of Dr 
around three months. This may be impacted by the current pandemic but where 
possible we are progressing our investigations whilst at the same time being mindful 
of the local environment and challenges. 

2.  Dr 

 – GMC Reference 

  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In addition to the actions of Dr 

 the GMC’s Triage team has also review Dr 
 involvement in the care provided. Our decision maker has decided that 
 actions.  

no further action or investigation should be carried out into Dr 

In making their decision they made the following comments: 

“We have carefully considered all of the information you provided within your 
Regulation 28 notification. We have also sought further information from the 
Responsible Officer (RO) at St Peter’s Hospital. 

We have reviewed a copy of the hospital’s Significant Incident report which 
explains that it is unlikely that Dr 
reduction in dose was appropriate, as it would not be her normal practice in 
this scenario as it would be contrary to established management principles. 

 would have advised that a 

Furthermore, the information we received indicated that it would normally be 
for the recipient of the advice to record it in the medical notes, and where a 
doctor is giving advice over the phone, the person giving the advice would 
not always be expected to record it.  

Taking this information into consider, it appears that the responsibility of 
ensuring a written record was made, did not lie with Dr 
see that there has been a full SI investigation which has addressed these 
issues, as such we don’t consider any further action is required by the GMC 
regarding Dr 

. We can 

.” 

I hope that this email has confirmed the actions and decisions taken in relation to 
the Regulation 28 report. If you would like to discuss this matter please do not 
hesitate to contact me on my direct telephone number.  

Kind Regards, 

Investigation Manager 

3 Hardman Street 
Manchester 
M3 3AW 

Web:        www.gmc-uk.org

Our Ref:  

Date:  7 January 2021    

Ms Caroline Topping 
Assistant Coroner for Surrey 
HM Coroner’s Court 
Station Approach 
Woking 
GU22 7AP 

Dear Ms Topping 

St Peter’s Hospital 
Guildford Road 
Chertsey 
Surrey 
KT16 0PZ 

DX 119775, Chertsey 2 

Tel 01932 872000 
Web www.ashfordstpeters.nhs.uk 
Text Relay prefix numbers with 18001 

Re: Mr Peter James Michael Unsworth 
Regulation 28 Report to Prevent Future Deaths 

Please find below my responses to your concerns raised following the inquest into the death 
of Mr Peter Unsworth. The Regulation 28 report sets out the matters giving rise to concern 
numbered 1- 2 below. 

1.  The advice provided by the Consultant Haematologist related to a very 

complex medical situation.  It was not recorded in writing.  The consultant 
Orthopaedic surgeon did not record it in the patient’s records nor email his 
understanding of the advice to the Consultant Haematologist for confirmation 
of what he understood the advice to be. 

2.  The Consultant Haematologist did not confirm her advice in writing or make 
any record of the advice given. As a consequence, there may have been a 
misunderstanding of the basis on which the advice was sought and/or given, 
and of the import of the advice. 

It has been understood and agreed practice nationally that the clinician requesting specialist 
advice should document the advice in the patient’s health record.  The Trust notes that the 
report has been sent to the national bodies and will embrace any changes recommended by 
them. 

As an organisation, the documentation of specialist advice had been embedded in the 
curriculum for Junior Doctors and is emphasised at regular Trust events.  The Trust takes 
the Situation, Background, Assessment, Recommendation (SBAR) approach to 
communication which is a structured framework for communication that enables information 
to be transferred accurately between individuals.  In addition, Human Factors training events 
are held regularly as part of the postgraduate education programme.  These events focus on 
improving documentation and communication between team members. 

Going forward the documenting of specialist advice will be further strengthened by the 
introduction of Electronic Patient Records which will allow clinicians to input information into 
health records in real time.  It is anticipated that this system will go live in December 2021. 

I hope the details of the changes the Trust has made to our practices are sufficient to allay 
the concerns you have raised in your report. 

Patients first          Personal responsibility          Passion for excellence          Pride in our team 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Please do not hesitate to contact me should you require further details or documentation. 

Yours sincerely 

Chief Executive 

Patients first          Personal responsibility          Passion for excellence          Pride in our team

Ms Caroline Topping  
HM Coroner’s Court 
Station Approach 
Woking 
Surrey 
GU22 7AP 
Sent via email to: 

Dear Ms Topping,    

9th February 2021 

Re: Regulation 28 Report – Action to Prevent Future Deaths dated 1st December 2020 following the conclusion of 
The Inquest Touching the Death of Peter James Michael Unsworth 

I understand that the Royal College of Surgeons of England have already responded to you but they did invite our 
association to comment as your report related specifically to the field of orthopaedic surgery. We agree with the RCS 
letter and its sentiments.  

Your report was discussed at length in Committee this week and we were all saddened to read the difficult 
circumstances that were described in your report and our sympathies go to the Unsworth family and friends.  

Members of our Orthopaedic Committee recognise that this was always a complex case and one that was likely to 
fall outside existing Trust protocols for the prevention of thromboembolism in the perioperative period. Hence 
appropriate discussion, explanation, consent and documentation were essential prior to any surgery. Overall, we 
recognise with some sadness that this situation may not be as unusual as we would wish it to be in busy arthroplasty 
units with a need to titrate carefully the risks vs benefits of anticoagulant therapy. We appreciate that although the 
literature on VTE (venous thromboembolic) prophylaxis does consist of high quality randomised trials, in many 
studies, patients such as Mr Unsworth with a known history of VTE events are excluded. Thus the evidence to 
support shared decision making in complex cases is relatively sparse. 

We are concerned that the relative risks of bleeding and increased infection vs thromboembolic problems are not 
well appreciated by physician colleagues and that existing hospital policies may not give advice on scenarios such as 
this.  

The BOA will be taking this further. We produce BOAST documents (British Orthopaedic Association Standards) and 
will be setting up a short life working group involving haematology colleagues to see if it would be possible to 
produce relevant guidance on the management of such cases in the future. 

Yours sincerely, 

Consultant Paediatric Orthopaedic Surgeon 
Assoc Prof University College London  
Vice President Elect BOA

21 December 2020 

Sent via email to: 

Private: Addressee Only 
Ms Caroline Topping 

Dear Ms Topping 

Regulation 28 Report re: Death of Mr Peter James Michael Unsworth 

Thank you for the ‘Regulation 28 Report – Action to Prevent Future Deaths’, addressed to 
 our Chair of Council.  I am responding as the Officer responsible for the 

Council’s fitness to practise work. 

I am grateful to you for bringing this matter to my attention.  We consider that 
information sharing is an essential part of the provision of safe and effective care.  Keeping 
patients’ medical records up to date is an important part of patient care, informing what 
happens in the future.  It also helps doctors to explain and justify their decisions and 
actions (see paragraph 50 in our Decision making and consent guidance).  Patients may 
be put at risk if those who provide their care do not have access to relevant, accurate and 
up to date information about them. 

We provide more information about medical records in our core piece of guidance, Good 
medical practice.  We state that the documents doctors make (including clinical records) to 
formally record their work must be clear, accurate and legible.  Records should be made at 
the same time as the events the doctor is recording or as soon as possible afterwards (see 
paragraph 19 Good medical practice). 

We also give a clear indication of what should be included in clinical records.  This 
includes, the drugs prescribed or other investigation or treatment, who is making the 
record and when, the decisions made and actions agreed, who is making the decisions 
and agreeing the actions, relevant clinical findings and the information given to patients, 
(see paragraph 21 of Good medical practice).  

We will consider the information you have provided and determine whether any further 
action is required either through our Outreach or fitness to practise process. 

 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 I hope this is helpful. 

Yours sincerely 

General Counsel 
Director, Fitness to Practise Directorate 
General Medical Council 

Telephone: 
Email: 

2

Ms Caroline Topping 
Assistant Coroner for Surrey 
HM Coroner’s Court 
Station Approach 
Woking 
GU22 7AP 

c/o

 Dear Ms Topping,  

NHS England & NHS Improvement  
Skipton House 
80 London Road 
London 
SE1 6LH 

16th March 2021 

Re: Regulation 28 Report to Prevent Future Deaths – Peter James Michael 
Unsworth, date of death 29th July 2018.  

Thank you for your Prevention of Future Deaths Report issued under Regulation 28 
of the Coroners’ (Investigations) Act 2013 (the “report”) dated 1 December 2020 
concerning the death of Peter James Michael Unsworth on 29th July 2018. Firstly, I 
would like to express my deep condolences to Mr Unsworth’s family.  

The regulation 28 report concludes Mr Unsworth’s death was a result of 1a 
Pulmonary Thrombo-Embolism and 1b Deep Vein Thrombosis. 

Following the inquest, you raised concerns in your report to NHS England and NHS 
Improvement regarding: 

1. The advice provided by the Consultant Haematologist related to a very complex 
medical situation. It was not recorded in writing. The Consultant Orthopaedic 
surgeon did not record it in the patient’s records nor email his understanding of the 
advice to the Consultant Haematologist for confirmation of what he understood the 
advice to be. 
2. The Consultant Haematologist did not confirm her advice in writing or make any 
record of the advice given. 
3. As a consequence, there may have been a misunderstanding of the basis on 
which the advice was sought and/or given, and of the import of the advice.  

The Trust carried out an internal investigation and recommended adopting a ‘read 
back’ approach to the provision of verbal clinical advice or information to check 
understanding of any advice. The Trust takes the Situation, Background, 
Assessment, Recommendation (SBAR) approach to communication which is a 
structured framework for communication that enables information to be transferred 
accurately between individuals.  In addition, Human Factors training events are held 

NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 regularly as part of the postgraduate education programme.  These events focus on 
improving documentation and communication between team members. 

For your second concern, the Trust has reiterated to all staff and clinicians the need 
to document verbal advice or information contemporaneously within the patient’s 
notes in line with GMC Good Medical Practice 19, 21 and continues to audit medical 
records to monitor this and other aspects of record keeping to reinforce good 
practice. As an organisation, the documentation of specialist advice had been 
embedded in the curriculum for Junior Doctors and is emphasised at regular Trust 
events.   

Going forward the documenting of specialist advice will be further strengthened by 
the introduction of Electronic Patient Records which will allow clinicians to input 
information into health records in real time.  It is anticipated that this system will go 
live within the Trust in December 2021. 

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

Yours sincerely, 

Medical Director for Professional Leadership and Clinical Effectiveness 
Lead Medical Director for Covid-19 Medical Workforce Cell 
NHS England and Improvement

Royal College of Physicians 
11 St Andrews Place 
Regent’s Park 
London NW1 4LE 

www.rcplondon.ac.uk 

Interim registrar 

 Ms Caroline Topping  
HM Coroner’s Court  
Station Approach  
Woking  
Surrey  
GU22 7AP  

Friday 12 March 

Dear Ms Topping 

Re: Regulation 28 Report - Mr Peter James Michael UNSWORTH 

The Royal College of Physicians (RCP) plays a leading role in the delivery of high quality patient care by 
setting standards of medical practice and promoting clinical excellence.  We provide physicians in the 
United Kingdom and overseas with education, training and support throughout their careers.  As an 
independent body representing over 39,000 Fellows and Members worldwide, we advise and work with 
government, the public, patients and other professions to improve health and healthcare.  

Thank you for sending your Section 28 notice to the President of the Royal College of Physicians. This reply is 
on behalf of the organisation following consultation with appropriate officers and partners.  

The matter of concern in your notice is of the recording and verifying of clinical advice given between 
clinicians. Whilst the Royal College of Physicians does not give specific advice to Physicians on this matter this 
is covered under GMC Good Medical Practice Duties of a Doctor  which states Clinical records should include: 
the decisions made and actions agreed, and who is making the decisions and agreeing the actions.  

As members of the Professional Record Standards Board (PRSB) we advise on elements of record standards. 
Following a review with PRSB the recording of advice is covered by GMC guidance, however standards to 
confirm the accuracy of that advice if it is given verbally is not currently covered in any standard. We have 
highlighted this as a member of PRSB. In response to learning from the CoViD 19 pandemic and the increase 
in the use of remote advice have proposed that standards are developed with respect to what elements of 
remote advice should be documented to ensure effectiveness and prevent harm. Where electronic records 
exist then this becomes much easier to implement as it is visible to both parties. We continue to advocate for 
the introduction of integrated electronic record systems within the NHS to enable this.  

Yours sincerely 

Interim RCP registrar

Ms Caroline Topping 
Assistant Coroner for Surrey 
HM Coroner’s Court 
Station Approach 
Woking 
GU22 7AP 
c/o 

Dear Ms Topping,  

25 January 2021 

Thank you for sending a copy of your Regulation 28 Report – Action to Prevent Future 
Deaths dated 1st December 2020 following the conclusion of the Inquest touching on the 
death of Peter James Michael Unsworth, addressed to 
President of the Royal College of Surgeons of England.  I am responding on behalf of 
as Chief Executive of the RCS (England).  

 as 

I was saddened to read the circumstances described in your report, and wanted to record 
my sympathy to Mr Unsworth’s family.  

We are grateful to you for bringing these circumstances to our attention and we have 
considered the matters of concern that you highlight in your report carefully.  

The Royal College of Surgeons (England) is clear that information sharing is an essential 
part of the provision of safe and effective care.  The need for effective and appropriate 
information sharing is a key part of our core guidance document for surgeons, Good Surgical 
Practice, and underpins our series of associated resources, and specifically our Good 
Practice Guides. 

For example, section 1.3 of Good Surgical Practice provides clear and detailed guidance to 
surgeons on the way that they can meet the standards of the GMC’s Good Medical Practice.  
This section specifically sets out that Surgeons must ensure that accurate, comprehensive, 
legible and contemporaneous records are maintained of all their interactions with patients, 
as well as ensuring that sufficiently detailed follow-up notes and discharge summaries are 
completed to allow another doctor to assess the care of the patient at any time.  Section 1.2 
of Good Surgical Practice describes the requirement for surgeons to ensure that patients 

The Royal College of Surgeons of England 
35-43 Lincoln’s Inn Fields 
London WC2A 3PE 

T: 
E: 
W: www.rcseng.ac.uk                                                                                             Registered Charity No. 212808 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 receive satisfactory postoperative care and that relevant information is promptly recorded 
and shared with the relevant teams, the patient and their supporters. 

The RCS also has engaged with the development of – and endorses - the detailed advice 
published by the Professional Record Standards Body and specifically their Standards for 
the Structure and Content of Health and Care Records.   

More widely in the area of supported decision making with patients we provide detailed 
advice and guidance to surgeons and patients through our Consent: Supported Decision 
Making Good Practice Guide, and in the area of working with colleagues we provide 
extensive good practice guidance through The High Performing Surgical Team and Surgical 
Leadership: a guide to best practice.  

As we hope the above demonstrates, we are committed to ensuring that all surgeons and 
those involved in the care of surgical patients are supported to deliver the highest standards 
of surgical care to patients.  

We would also nevertheless reassure you that we will continue to consider the 
circumstances you describe in your report, and specifically the matters of concern you 
identify in your desire that actions are taken to prevent future deaths.  Specifically, we will 
ensure that we consider this in detail within our programme of standards and good practice 
guidance review and development for 2021, and throughout our supporting wider 
communication and awareness raising around this activity as part of our continuing efforts to 
ensure all patients receive the highest standards of surgical care. 

We have also shared your correspondence with our colleagues within the British 
Orthopaedic Association to enable them to do the same. 

Yours sincerely, 

Chief Executive