Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0280, written 7 Sep 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Sep 2022 |
|---|---|
| Reference | 2022-0280 |
| Deceased | Michael Rolfe |
| Coroner | Paul Cooper |
| Coroner area | Lincolnshire |
| 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: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 United Lincolnshire Hospital 1 CORONER I am Paul COOPER, HM Assistant Coroner for the coroner area of Lincolnshire 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 02 September 2019 I commenced an investigation into the death of Michael James Robert ROLFE aged 72. The investigation concluded at the end of the inquest on 07 September 2022. The conclusion of the inquest was that: The deceased presented on 23rd August 2019 to A& E at the Pilgrim Hospital, Boston. A CT scan disclosed an intercranial bleed. He was not a candidate for surgery. Anti coagulants had already been stopped. He declined and died. 4 CIRCUMSTANCES OF THE DEATH Integrated Assessment Centre, Pilgrim hospital Referral from Due to death within 24hrs of admission. Mr Rolfe is a 72 yr old man admitted on 23/8/19 at 1627hrs with decreasing consciousness. He had a heache one day prior to admission. CT scan showed left cerebellar haemorrhage with intraventricular extension, compression of fourth ventricle and brainstem and obstructive hydrocephalus. ITU team initially intubated and ventilated him. However after discussion with QMC Neurosurgery, who were of the opinion that the position was not treatable. Discussion was had with family. He was extubated at 2350hrs the same day and transferred to the Stroke ward for EOLC. He passed away at 0930hrs on 24/8/19. PMH: TYPE 2 Diabetes mellitus, hypertension, non alcoholic steato hepatitis, hepatic encephalopathy, monoclonal gammopathy of undetermined significance, recent deep vein thrombosis started on Rivoroxaban, recent rectal bleeding. Spoke to the bleed/death. He will liaise with his Consultant Coroner's report. Decision taken for Consultant who is of the opinion that the Rivaroxaban most likely played a part in to complete circumstances of death with CoD. (F) as to who will complete the 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) Regulation 28 – After Inquest Document Template Updated 30/07/2021 With reference to cause of death at 1b. The deceased had liver impairment due to cirrhosis. He was prescribed the anticoagulant Rivaroxaban for presumed deep vein thrombosis. Within 48 hours he developed rectal bleeding. During his admission to hospital his INR was 1.8 indicating blood was thin. Renal function impaired with a GFR of 39 - baseline 46. Rivaroxaban is contradicted in liver impairment, low platelets and severe renal impairment .(Documented in the product literature and British National Formulary). Consequently, it is represented that the deceased should not have been prescribed Rivaroxaban due to the bleeding risk. Administration of Rivaroxaban to someone with impaired clotting and low platelets would exaggerate the anticoagulant effect and be responsible for the rectal bleed and cerebral haemorrhage that resulted. If accepted the potential inappropriate administration may have led to the cause of death and this has important safety implications that are in the public interest. An action plan to prevent future deaths may be needed. 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 November 02, 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 Chief Coroner and to the following Interested Persons I have also sent it to who may find it useful or of interest. 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 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 by the Chief Coroner. 9 Dated: 07/09/2022 Paul COOPER HM Assistant Coroner for Lincolnshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Liquorpond Surgery Coroners Inquest Letter County of Lincolnshire Lindum Road Lincoln LN21NN Dear Sir/Madam Re: Michael Rolfe d.o.b: 16 Apr 1947 12th May 2023 Mr Michael James Robert Rolfe, DOB: 16/04/1947 was a 72-year-old gentleman with background of hype1tension, benign prostate hyperplasia, Monoclonal gammopathy of undetermined significance (MGUS), liver cirrhosis due to non-alcoholic steatohepatitis, hepatic encephalopathy and diet-controlled type 2 diabetes mellitus. His regular medications included Bisoprolol Lansoprazole once a day, Valsartan required, Colecalciferol cream. / calcium carbonate once a day, Furosemide once a day, lactulose once a day, twice a day as one tablet twice a day and Aquamax The information in this letter is based on Mr Rolfe's medical notes only as I was not involved in his care and is no longer at Liquorpond surgery. Mr Rolfe had a consultation with on the 21/08/2019 at 12:26 and presented with a swollen and bruised right lower leg which was tender. He denied any trauma to the leg and denied any recent travel or operations. The entry describes that Mr Rolfe had been trying to walk more and he did not have previous history of deep vein thrombosis (DVT). From the examination the right lower leg was swollen and appeared bruised and there was tenderness on palpation. 10 Liquorpond Street Boston Lincolnshire PE21 8UE Website: \vww.liquorpond-surgery .co. uk He was started on Rivaroxaban referred him to have a doppler ultrasound scan of the leg. The referral was done during the consulta.ti on. twice a day for suspected deep vein thrombosis and According to the discharge letter from Pilgrim hospital dated the 22nd of August 2019 at 11 :23, Mr Rolfe attended the DVT clinic on the 22/08/2019 due to right leg tenderness and the ultrasound doppler showed no evidence ofDVT in all venous segments. The discharge letter mentioned that ifRivaroxaban was commenced for DVT cover then it can stop. Mr Rolfe attended the accident and emergency department at Pilgrim hospital on the 23/08/2019 at 16:27 with blood in his stools and passing blood clots. The suspected diagnosis was Hepatic failure or coma. He was intubated by the intensive treatment unit team due to low GCS (Glasgow Coma Scale) score. He sadly passed away on the 24th of August 2019. Yours faithfully 10 Liquorpond Street Boston Lincolnshire PE21 SUE Website: ,vww.liquorpond-surgery.co.uk
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