Prevention of Future Deaths reports · 2022

Michael Rolfe

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 report7 Sep 2022
Reference2022-0280
DeceasedMichael Rolfe
CoronerPaul Cooper
Coroner areaLincolnshire
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Responses

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.

Response from Liquorpond Surgery (PDF)
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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