Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0340, written 12 Oct 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Oct 2021 |
|---|---|
| Reference | 2021-0340 |
| Deceased | Vivien Brunning |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
MR G IRVINE
ACTING SENIOR CORONER
EAST LONDON
Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. n°. BHRUT NHS Trust, Queens Hospital, Rom Valley Way,
Romford, RM7 OAG
2. Department of Health & Social Care
CORONER
| am Graeme Irvine, acting senior coroner, for the coroner area of East London
CORONER’S LEGAL POWERS
| 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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www. legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 27* July 2020 | commenced an investigation into the death of Mrs Vivien Brunning,
aged 87 years. The investigation concluded at the end of the inquest on 7" October
2021. The conclusion of the inquest was that Mrs Brunning died from;
1a Right Basal Ganglia and Occipital Lobe Ischaemic Strokes
1b Atheromatous thromboembolism during attempted thrombolysis for right brachial
artery thrombosis
1c Urosepsis and urinary tract obstruction (treated); systemic atheromatosis,
hypercoagulability (omission of clexane therapy)
Il Diabetes Mellitus; atrial fibrillation A short form conclusion of accidental death was
arrived at.
A narrative conclusion was arrived at.
CIRCUMSTANCES OF THE DEATH
On 9th July 2020 Mrs Vivien Brunning was admitted to hospital with sepsis. Mrs
Brunning had been treated in the community with anti-coagulants for atrial fibrillation.
In hospital, a venous thromboembolism ("VTE") assessment indicated that Mrs Brunning
required prophylaxis to mitigate the risk of developing deep vein thrombosis as an
inpatient, she was prescribed low molecular weight heparin ("Clexane").
Mrs Brunning was diagnosed with a kidney stone and underwent a nephrostomy to treat
the source of her infection. As a precaution, clexane was held, temporarily, to mitigate
the risk of bleeding in the procedure.
Following the procedure, clexane was to be resumed and was administered on 12th July
2020.
On 13 & 14th July 2020 clexane was not administered to Mrs Brunning, in error.
On 15th July 2020 Mrs Brunning was diagnosed with a thrombosis in her right brachial
artery, a causal factor in the formation of the clot were the two missed doses of clexane.
Mrs Brunning underwent an emergency thrombolysis procedure to dissolve the clot,
during the procedure she suffered a stroke due to a recognised complication of the
essential, emergency procedure.
Mrs Brunning died on 25th July 2020 due to the effects of the stroke.
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 could 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. The hospital notes demonstrate that required venous thromboembolism reviews
at 24 & 72 hrs following admission were not undertaken.
2. Prescribed daily injections of low molecular weight heparin were omitted on 13
and 14" July 2020
3. The initial omission on 13" July 2020 was noticed by a ward doctor but was not
reported through the Trust's incident reporting system.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 7" December 2021, |, 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.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons the family of Mrs Brunning and the CQC. | have also sent it to the local Director
for Public Health who may find it useful or of interest.
| am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
| may also send a copy of your response to any other person who | believe may find it
useful or of interest.
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
|
[DATE] 12" October 2021 [SIGNED BY CORONER]
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.
THE CROFT SH/FA HEALTH CENTRE BELFIELD ROAD, ROCHDALE, LANCS. OL16 2UP Ms McKenna HM Coroners' Court 2nd Floor Newgate House Newgate Rochdale OL16 1AT 23/02/2022 Re: Regulation 28 report Dear Ms McKenna With reference to the above and your concerns regarding patient documentation workflow within the practice. We conducted a practice meeting including GP's as well as all administration staff on 20/01/22. Staff were informed regarding the events of the lead up to the passing of Sameena Javed and your concerns regarding the management of patient DNA and Home Visit notifications and how they are currently processed at the practice. The existing records management policy was discussed, and the following changes were agreed: All DNA and Bardoc visit notifications received, whether by normal post/Docman/e-mail, to have date of receipt stamped and scanned if received as paper copy and forwarded to the addressed GP to be reviewed. All documents received via Docman should be work flowed to the addressee, if the GP is on annual or sick leave then the documents should be sent to the GP on-call. All staff were directed that this policy is to be implemented immediately. The amended policy will be updated by the practice manager and replaced in the practice policy folder held in the administration office as well on the practice shared drive folder which is on all computers and to be included in the induction of new staff. We hope that you will be satisfied that we have taken the advised and necessary course of action to ensure that there are no future cases of lapsed patient information and care being forwarded to GPs within our practice. I apologies that I have not been able to forward the policy to you earlier. I have been away from work caring for my mother and then due to having Covid. Please accept my apologies. Yours sincerely Practice Manager
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