Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0064, written 28 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Feb 2022 |
|---|---|
| Reference | 2022-0064 |
| Deceased | Neil Hickman |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) 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: Prevention of Future Deaths report Neil HICKMAN (died 21.08.21) THIS REPORT IS BEING SENT TO: 1. Chief Medical Officer East Kent Hospitals University NHS Foundation Trust Kent & Canterbury Hospital Ethelbert Road Canterbury Kent CT1 3NG 1 CORONER I am: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 2 CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3 INVESTIGATION and INQUEST On 25 August 2021, one of my assistant coroners, Sarah Bourke, commenced an investigation into the death of Neil Hickman aged 63 years. The investigation concluded at the end of the inquest earlier today. I made a determination at inquest of death by natural causes. 4 CIRCUMSTANCES OF THE DEATH Neil Hickman was treated at Kent and Canterbury Hospital (K&C) for myelodysplastic syndrome and then was referred to University College London Hospital (UCLH) for stem cell transplant. However, he died before the transplant could take place. His medical cause of death was: 1 disseminated angio-invasive mycotic infection immunosuppression 1a 1b 1c myelodysplasia 5 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. Mr Hickman was given frequent platelet transfusions at K&C, but his ferritin levels were not measured. When he was referred to UCLH, his ferritin level was found to be hugely raised. He was then treated with chelation therapy and ultimately his ferritin returned to a safe level, so this did not impact upon the outcome. However, it might for another patient. I think the reason that K&C does not measure the ferritin levels in such a situation is because K&C does not have funding for chelation therapy to treat iron overload. However, if iron overload is detected, then a referral centre such as UCLH can be called for advice, and the patient and their family can be informed so that they have the option of seeking private treatment. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you 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 25 April 2022. 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 following. 2 • • University College London Hospitals NHS Trust • HHJ Thomas Teague QC, the Chief Coroner of England & Wales , wife of Neil Hickman I 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. I may also send a copy of your response to any other person who I 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. 9 DATE SIGNED BY SENIOR CORONER 28.02.22 ME Hassell 3
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.
S Trust Offices Kent & Canterbury Hospital Ethelbert Road Canterbury, Kent CT1 3NG ME Hassell HM Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Your Ref: 30 March 2022 From: Susan Acott, Chief Executive Dear Madam Mr Neil Hickman – PFD Response Thank you for your Prevention of Future Death (PFD) Report dated 28 February 2022 sent pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 concerning the death of Mr Neil Hickman on 21 August 2021. I understand that during the course of the inquest you heard evidence that revealed matters giving a rise to a concern that needs to be addressed to prevent a future death. Specifically, you are concerned that when Mr Hickman was referred for a bone marrow transplant, his ferritin levels were not checked despite him undergoing frequent blood transfusions. Your PFD Report was discussed in the Haematology Departmental business meeting on 10 March 2022. It has now been agreed that all Myelodysplastic Syndrome patients that are undergoing frequent red cell transfusions and being referred for a bone marrow transplant will have their ferritin levels measured. This will ensure that if iron overload is detected, appropriate measures can be initiated including referral to a specialist centre for urgent treatment. This action has been implemented with immediate effect. Lastly, I would like to thank you for bringing your concern to our attention and can assure you and Mr Hickman’s family that the Trust will continue to improve on the high standards we set ourselves in East Kent Hospitals. Yours sincerely Chief Executive
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.