Christopher Collinson

Monday 20th December 2021 

For the attention of Rebecca Ollivere 
Assistant Coroner for Birmingham and Solihull 
Birmingham Coroner’s Court 
50 Newton Street 
Birmingham 

Dear Ms Ollivere, 

Inquest touching the death of Christopher Collinson 
Response to Regulation 28 Report to prevent future deaths 

I write in response to the Regulation 28 Report made by you following the Inquest touching 
the death of Mr Collinson which concluded on 26 October 2021. 

University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered 
the concerns raised within your report to prevent future deaths, which relate to the potential 
for  delay  in  patient  assessment  and  secondary  checks  when  selecting  medication  and  we 
would respond as follows. 

Potential for delay in patient assessment 

At the time of Mr Collinson’s admission to AMU, patient records at Birmingham Heartland’s 
Hospital (BHH) were predominantly paper based.   Within AMU clinicians were expected to 
confirm their assumption of clinical responsibility for the care of a patient by logging in to  a 
system which provided a list of all the patients on the ward at that specific time.  

In this case, the junior doctor who took on Mr Collinson’s care, logged on to the electronic 
system assuming responsibility for reviewing Mr Collinson and then proceeded to look for Mr 
Collinson’s  paper  records  in  order  to  review  them  and  assess  him.      The  doctor  became 
distracted  looking  after  another  sick  patient  and  unfortunately  did  not  remove  their  name 
from Mr Collinson’s record on the electronic system. This was interpreted as completion of 
clinical assessment of Mr Collinson by other clinicians in AMU which led to the delay in Mr 
Collinson’s clinical assessment and management.  

Following  Mr  Collinson’s  admission,  the  above  process  has  been  updated  and  we  have 
rolled  out  our  in-house  electronic  system,  PICS  to  BHH.  PICS  has  been  in  use  in  AMU  at 
BHH  since  July  2021.  PICS  provides  a  paper-free  electronic  patient  record  system  that 
allows  for  simultaneous  access  and  entries  to  the  record  of  a  single  patient  by  multiple 
clinicians. With PICS, it is easy to access and review patient records at any time.   To ensure 
patients are seen without delay, there are time markers on the system which indicate when 
patients have been waiting to be seen for a period of time without progression.  This allows 

 
 those  co-ordinating  care  to  see  clearly  which  patients  are  waiting  to  be  seen  and  are  not 
progressing.    The  system  highlights  those  patients  who  are  not  progressing  in  ‘red’  which 
highlights  that  there  has  been  too  long  a  delay  and  this  can  easily  be  seen  by  the  co-
ordinators. 

As  the  notes are  now  electronic,  it  is  very  easy  for  staff to identify  what  has  actually  been 
done,  what  it  outstanding,  with  clear makers,  as  referred  to  above,  where patient  care  has 
not progressed. 

PICS  allows  for  a  quick  visual  summary  of  patients  who  are  awaiting  assessment  thereby 
reducing the risk of delay in assessment.   

We are  confident  that  with the  use  of  PICS  in  BHH,  the  possibility  of  unfortunate  incidents 
similar to those surrounding the care of Mr Collinson has been minimised.   

Secondary check within electronic prescribing system 

The Trust currently has 2 electronic prescribing medication administration (EPMA) systems. 
This is a result of the merger of Heart of England Foundation Trust with UHBFT which had a 
different  EPMA  system  in  place.   Work  is  already  underway  to  implement  a  single  system 
which will be in place across all of our sites by the middle of 2022. The system in place at 
BHH  during  Mr  Collinson’s  admission  was  ‘JAC’,  a  commercial  EPMA  system  which  had 
been in use for many years.  

Within your  report  you  state that “the  Doctor  prescribed a prophylactic dose  of  Enoxaparin 
rather  than  the  therapeutic  dose  which  she  had  intended  to  prescribe.  The  reason  for  this 
was that the electronic prescribing system is a drop-down box with confusing tables to select 
the medication.”  

To provide some context, Mr Collinson was prescribed a single dose of enoxaparin, the dose 
of  which  was  lower  than  that  indicated  for  treatment  of  venous  thromboembolism.  The 
patient  died  soon  after  admission.  He  had  been  seen  11  days  earlier  in  primary  care  with 
what in hindsight appears to have been symptoms of a DVT. 

The  doctor  who  had  prescribed  the  medication  accepted  that  the  incorrect  dose  of 
enoxaparin  was  as  a  result  of  human  error.  This  was  also  the  finding  of  a  carefully 
conducted internal investigation.  
The  prescription  required  a  choice  to  be  made  of  the  correct  dose  according  to  indication 
and patient weight as shown in Fig 1 below.  

Clinical Decision Support 

Clinical decision support exists within electronic systems to support clinical processes and to 
help  clinicians  to  ‘do  the  right  thing’.  Examples  include  allergy  checking,  assessment  of 
interactions, critical pop-up alerts and evidence-based order sets. In the case of prescribing, 
an  order  set  can  provide  rapid access  to  the  most  commonly  prescribed dose, form,  route 
and  frequency  of  administration.  It  is  recognised  that  this  reduces  the  rate  of  execution 
errors,  thereby  improving  patient  safety.  For  example,  in  adult  practice  an  order  sentence 
might be ‘Paracetamol 500mg tablets – 2 tablets – by mouth – four times per day’. Defaulting 
to the most common sentence promotes safe and effective prescribing.  

Enoxaparin does not have a single prescribable dose because there is variation in dose and 
frequency  according  to  patient  weight,  renal  function  and  indication;  (for  example  different 
daily doses and frequency for treatment or prophylaxis of venous thrombo-embolism). Using 

 
 
 
 
 
 
 
 
 
 
 
 
 paper,  a  prescriber  has  to  make  all  these  decisions  themselves,  often  having  to  do  a 
calculation  of  dosing  according  to  a  patient’s  weight  to  obtain  the  correct  dose,  a situation 
potentially  prone  to  error.  This  risk  is  mitigated  in  different  ways  in  different  electronic 
systems however these all seek to incorporate knowledge of these variables, to then provide 
a prescription within an allowed safe range. For the JAC system, this is illustrated in Fig 1.  

Figure 1: Enoxaparin treatment protocols within the JAC EPMA system 

EPMA systems such as JAC, can assist by providing evidence-based options as illustrated 
In  Figure  1,  thus  providing  the  correct  dosage  for  the  patient  according  to  the  determining 
variables. 

There is however little evidence to suggest that introducing an additional double-check into 
the  individual  prescriber’s  workflow  improves  patient  safety.  On  the  other  hand,  there  is 
evidence  of  risks  associated  with  introducing  many  more  alerts.  This  is  a  consequence  of 
alert fatigue discussed in more detail below.  

There  are  exceptional  situations  in  which  an  incorrect  prescription  is  so  immediately 
hazardous  that  a  cross-check  is  made  by  another  individual  during  the  workflow.  For 
example,  this  occurs  for  cytotoxic  chemotherapy.  However,  for  most  medications,  cross-
checking  by  other  individuals  is  displaced  in  time,  occurring  on  ward  rounds,  in  which 
prescriptions are repeatedly checked, over time, by different individuals.   

Sociotechnical Issues, alerting and alert fatigue 

Even  though  electronic  prescribing  systems  with  clinical  decision  support  may  include 
features that protect against individual error and thus enhance patient safety, they also have 
the potential to be confounded by new types of error. For example, dosing errors, such as 
10-fold  increases  in  dosing  (additional  0  introduced  into  prescription)  can  be  mitigated  in 
various  ways,  including  drop  downs  of  allowed  doses,  or  automated  checking  and 

 
 
 
 
  
 
 
 
 
 
 interruptive alerting against allowed dose ranges. As discussed above, dose variation within 
the  allowed  range  is  considerably  more  difficult  to  address.  This  can  be  mitigated  by 
associating indication with the  prescription (for  example ENOXAPARIN  FOR TREATMENT 
or  ENOXPARAIN  FOR  PROPHYLAXIS).  As  this  case  illustrates  even  this  cannot  always 
prevent some types of slip error.  

Not  only  does  introduction  of  a  double-check  into  the  individual  prescriber’s  workflow  not 
necessarily  reduce  risk;  there  is  a  significant  body  of  evidence  that  the  addition  of  such 
alerting results in the phenomenon of alert fatigue. Alert fatigue is defined as a “condition in 
which  too  many  alerts  consume  time  and  mental  energy  to  the  point  that  both  important 
warnings  and  clinically  unimportant  ones  can  be  ignored.”  It  is  well  described  in  the 
literature;  the  term  appears  14  times  in  the  body  of  a  recent  report  by  the  Health  Safety 
Investigation Branch on electronic prescribing systems and safe discharge. 

While alerts can change clinician decision making, as they increase there is progressive rise 
in  the  proportion  that  are  over-ridden.  For  example,  drug  interactions  often  result  in  many 
clinical alerts; however these are overridden in nearly all cases (up to 95% in some studies). 
Overrides may be clinically appropriate, such as when a clinician deems the likely benefit of 
administering  a  medication  to  exceed  the  potential  medication  risks.  In  other  cases, 
overrides may represent not carefully considered clinical decisions, but reflexive dismissals 
by  clinicians  who  have  become  inured  to  the  large  number  of  alerts.  This  is  particularly 
common in a situation in which a prescriber is invited to confirm the prescription just entered, 
as opposed to an interruptive alert that prevents prescriptions outside of allowed parameters. 
It is our view that there is therefore a high risk that introducing the suggested second check 
introduces so many alerts that high value alerts are inadvertently missed, whilst achieving no 
meaningful  benefit.  This  is  particularly  the  case  when  an  EPMA  already  has  significant 
design features to minimise the risk of error, in this case indication and weight.  

Is a secondary check required? 

When a prescriber picks from a list, they are performing an affirmative action. Introducing a 
new alert to say “are you sure you want to pick enoxaparin treatment for your patient” every 
time that this is prescribed will quickly lead to alert fatigue. The prescriber is very quickly not 
going to read the contents of the message and instead click ‘yes’ to get to the next action. 
(For context there are approximately 8000 prescriptions for enoxaparin every month across 
UHBFT. There are >  1 million  drug  administrations  every  month,  all  supported  by  carefully 
designed clinical decision support). 

We  believe  that  the  balance  of  risk  and  benefit  is  against  routinely  introducing  such  a 
double-check step in the process of prescribing. This decision would be consistent with the 
current scientific literature and the collective approach of clinical safety officers responsible 
for  the  introduction  and  maintenance  of  EPMA.  A  selection  of  relevant  references  are 
attached to this response. 

Based  on  the  review  of  our  systems  and  relevant  literature,  we  are  confident  that  the 
systems and processes that we have in place are sufficient to minimise risk to our patients.  
We are satisfied that our decision not to introduce an additional double-check step has been 
carefully considered and is consistent with the collective approach of those responsible for 
introducing and maintaining EPMA systems. 

 
 
 
 
 
 
 
 
 
 
 
 
 I  would  like  to  assure  you  that  the  concerns  raised  within  the  Regulation  28  Report  have 
been taken extremely seriously which I hope is demonstrated by our response above.  

Yours sincerely 

Professor 
Chief Medical Officer