Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0238, written 13 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jul 2021 |
|---|---|
| Reference | 2021-0238 |
| Deceased | Jonathan Kingsman |
| Coroner | Simon Milburn |
| Coroner area | Cambridgeshire & Peterborough |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths |
| 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 (1) NOTE: This from is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 The Secretary of State for the Department of Health, Ministerial Correspondence and Public Enquiries Unit, Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU 1 CORONER I am Simon MILBURN, Area Coroner for the area of Cambridgeshire and Peterborough 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 13.03.20 I commenced an Investigation into the death of Jonathan Mark Kingsman, aged 47 years. The Investigation concluded at the end of the Inquest on 12.07.21. The conclusion of the Inquest was that death was as a result of ‘Natural Causes’, The medical cause of death being recorded as: 1a Pulmonary Thromboembolism; 1b Deep Vein Thrombosis; 4 CIRCUMSTANCES OF THE DEATH Mr Kingsman was admitted to Fulbourn Hospital, Cambridge under s2 of the Mental Health Act 1983 on 26.01.21 where he remained until his death on 01.02.20. On admission it was reported that Mr Kingsman had not consumed any fluids for at least several hours. The Doctor on call carried out an initial risk assessment using the Department of Health Template titled ‘Risk Assessment for Venous Thromboembolism(VTE)’ Gateway reference no: 10278. At ‘Step 1’ the document requires an assessment of the patient’s anticipated mobility. Where the patient is ‘NOT expected to have significantly reduced mobility relative to normal state’ the assessor is directed to terminate the assessment. It was agreed evidence at the Inquest that Mr Kingsman fell into this category and likewise agreed that throughout his time in hospital that there were no changes to his mobility which would have prompted a renewed risk assessment. The Inquest also heard evidence that ‘immobility’ was one of a number of potential risk factors for VTE. These included:- obesity; inherited blood clotting disorder; smoking; personal or family history of DVT or PE; dehydration; receipt of certain psychiatric medication(there are others listed on the risk assessment form itself). At least some of these potential risk factors may have been present in this case although on the evidence presented it was not possible to conclude to the required standard which, if any, may have played a part in Mr Kingsman’s death. None of these risk factors was considered as part of the risk assessment process as Mr Kingsman did not get past ‘Step 1’ referred to above. Additional risk factors including those identified above are only considered at ‘Step 2’ in the risk assessment process. The evidence was that at no stage during his hospital admission was Mr Kingsman ‘expected to have significantly reduced mobility relative to normal state’ and therefore there was no stage at which these risk factors were prompted for consideration at ‘Step 2’ in the risk assessment process. Despite this Mr Kingsman died as a direct result of a pulmonary thromboembolism caused by deep vein thrombosis. The Inquest was also advised that the risk assessment form contains no guidance on its completion and no definitions of some of the terms used eg ‘significantly reduced mobility compared to normal state’; 5 CORONER’S CONCERNS The MATTERS OF CONCERNS are as follows: (brief summary of matters of concern) That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased immobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future; The risk assessment form contains no guidance on its completion and no definition of certain terms. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 07 September 2021. 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 – Next of Kin Cambridgeshire & Peterborough Foundation Trust – Mental Health Service Provider 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 Simon MILBURN Area Coroner for Cambridgeshire and Peterborough Dated: 13/07/2021
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.
From Maria Caulfield MP Parliamentary Under Secretary of State for Primary Care and Patient Safety 39 Victoria Street London SW1H 0EU Mr Simon Milburn HM Area Coroner, Cambridgeshire and Peterborough Lawrence Court Princes Street Huntingdon PE29 3PA Dear Mr Milburn 18 November 2021 Thank you for your letter of 13 July 2021 to Sajid Javid about the death of Jonathan Mark Kingsman. I am replying as Minister with responsibility for patient safety and I am grateful for the additional time in which to do so. To begin, I would like to offer my sincere condolences to Mr Kingsman’s family and loved ones. I can appreciate how upsetting the circumstances around his death must be. I have noted carefully your concerns in relation to the Department of Health 2010 Risk Assessment Tool for Venous Thromboembolism (VTE)1. In preparing this response, my officials have made enquiries with NHS England and NHS Improvement (NHSEI), and the National Institute for Health and Care Excellence (NICE). I am advised that NICE guideline 89: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism2, is clear that all acute psychiatric patients should be assessed to identify their risk of VTE and bleeding: • As soon as possible after admission to hospital or by the time of the first consultant review; and, • Using a tool published by a national UK body, professional network or peer reviewed journal. NICE does not recommend a particular risk assessment tool, as there is no evidence currently to support the use of one over another. The Guideline explains that a tool commonly used in the NHS for hospital patients is the Department of Health Risk Assessment Tool for Venous Thromboembolism (VTE) (2010) (see Recommendation 1.9.1). 1 Risk assessment for venous thromboembolism (VTE) (nice.org.uk) 2 Overview | Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism | Guidance | NICE The 2010 Department of Health Risk Assessment Tool acknowledges that the risk factors identified are not exhaustive, and that clinicians may consider additional risks in individual patients and offer thromboprophylaxis (preventative measures against the formation of blood clots) as appropriate. NICE Guideline 89 notes that the 2010 Department of Health Risk Assessment Tool has not been validated or tested against other tools to evaluate its diagnostic accuracy or effectiveness at correctly identifying people at risk of VTE. The NICE Guideline Committee made a research recommendation in this area, reflecting the uncertainty in the evidence for one risk tool over another but supports its use until tools that incorporate new evidence and have been tested through research can replace it. You may wish to note that NICE has advised that it will consider the use of specific tools for acute psychiatric patients at its next review of Guideline 89. I am advised by NHSEI that there is a recognised need for research to be conducted to identify the balance of risk of VTE versus the risk of bleeding with VTE prophylaxis for some groups where NICE requires this (including for acute psychiatry settings) to inform the development of new evidence-based risk assessment tools. I am informed by the National Institute for Health Research (NIHR) that it has supported or funded a number of research studies in relation to VTE prevention. This includes studies in relation to the cost-effectiveness of VTE risk assessment tools for hospital inpatients and looking at the risk of VTE in patients admitted to acute psychiatric wards. NHSEI advise that once these studies are complete, it will then be feasible to create an updated tool to encompass patients on acute psychiatry wards, where NICE guidelines recommend that VTE prophylaxis (usually through injections of Low Molecular Weight Heparin) should be given if the risk of VTE exceeds the risks of bleeding. The National Patient Safety Committee will work to identify the best route to take this forward. More generally, VTE prevention continues to be an area of significant focus in relation to patient safety. The ‘Getting it Right First Time’ (GIRFT) Programme has undertaken a national survey in partnership with Thrombosis UK and published a report in September 20213, that makes recommendations for improvement that providers of care can take forward, as well as recommendations to NICE. In addition, the National Patient Safety Committee is currently working to understand, and improve, the contributions that each partner organisation can make in the prevention of healthcare associated VTE. I hope this response is helpful. Thank you for bringing these concerns to my attention. MARIA CAULFIELD Minister for Primary Care & Patient Safety 3 TUK-GIRFT-REPORT.pdf (thrombosisuk.org)
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