Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0152, written 15 May 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 May 2023 |
|---|---|
| Reference | 2023-0152 |
| Deceased | Rebekah Mills |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: NHS England and NICE (National Institute for Health and Care Excellence) 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 3rd August 2022 I commenced an investigation into the death of Rebekah Juliet Mills. The investigation concluded on the 6th February 2023 and the conclusion was one of Narrative: Died from post-operative complications of surgery following an accidental fall resulting in injury. The medical cause of death was 1a) Pulmonary Embolus; 1b) Post Meniscus Repair 4 CIRCUMSTANCES OF THE DEATH Rebekah Juliet Mills had an accidental fall when skiing and she hurt her knee. She went to Stepping Hill Hospital and was seen in the Emergency Department. An examination identified no obvious injury. The notes did not capture her being on oral contraceptive or the degree of her lack of mobility. The virtual fracture clinic review on 13th June 2022 referred her to the physiotherapy team for an appointment. Backlogs meant this did not take place as envisaged. On 22nd June she sought further help. She was seen on 11th July and a scan on 13th July identified a significant knee injury that had caused her knee to lock. She was seen on 21st July, and it was identified as repairable with surgery, but the surgery was urgently required. She was asked to stop taking oral contraceptive (a risk factor for surgery) which she did. On 28th July 2022 she was operated on. She was discharged home. On 1st August 2022 she collapsed and was taken to Stepping Hill Hospital where she died from a pulmonary embolism. 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. 1 The MATTERS OF CONCERN are as follows. – During the course of the inquest evidence was given that the guidance for clinicians in relation to reducing the risk of DVT when dealing with patients such as Ms Mills who are young and on oral contraception but are immobile following an accident and require surgery is unclear. That lack of clarity can give rise to a differing approach and a lack of recognition of the potentially fatal risk that patients such as Ms Mills can face in such a situation. The evidence was that greater clarity and greater understanding of the risks could prevent future deaths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 10th July 2023. 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 namely 1) Stockport NHS Foundation Trust, who may find it useful or of interest. on behalf of the Family, and; 2) I am also under a duty to send the Chief Coroner a copy of your response. 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 Alison Mutch HM Senior Coroner 15.05.2023 2
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.
10 South Colonnade Canary Wharf London E14 4PU United Kingdom gov.uk/mhra Alison Mutch HM Senior Coroner Greater Manchester South Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG 25 October 2023 Dear Ms Mutch, Re: Regulation 28 Report to Prevent Future Deaths – Rebekah Juliet Mills who died on 1 August 2022 Thank you for your email of 22nd August 2023 in which you asked the Medicines and Healthcare products Regulatory Agency (MHRA) to provide a response to the Regulation 28 Report to Prevent Future Deaths concerning the sad death of Rebekah Juliet Mills. Please convey our sincere condolences to Rebekah’s family. We have considered the information provided and the circumstances included in the report and our response includes the matters that fall under the remit of the MHRA. In addition, we have noted the responses provided from NHS England and the National Institute for Health and Care Excellence (NICE). Your report listed two matters of concern: • You have raised the concern that the guidance for clinicians in relation to reducing the risk of DVT when dealing with patients who are young and on oral contraception but are immobile following an accident and require surgery is unclear. • That this lack of clarity can give rise to a differing approach and a lack of recognition of the potentially fatal risk that patients such as Ms Mills can face in such a situation. In the UK, medicines are regulated by the MHRA to ensure that they meet the necessary standards of safety, efficacy, and quality. The MHRA monitors the safety of medicines in clinical use and approves the authorised product information, which comprises the Summary of Product Characteristics (SmPC, intended for healthcare professionals) and Patient Information Leaflet (PIL, provided to patients in each medicine pack) and outer packaging. All oral hormonal contraceptives licensed in the UK have included warnings in the SmPC since the early 2000s on the risks of venous thromboembolism (VTE) which includes deep vein thrombosis (DVT) and pulmonary embolism. These warnings highlight the need to stop treatment at least 4 weeks prior to and for 2 weeks after elective operations and during immobilisation. The risks of VTE with combined hormonal contraceptives were further reviewed in 2013 by MHRA in conjunction with other regulators in the EU. The review confirmed the known relative risks of VTE for different groups of combined hormonal contraceptives (newer contraceptives compared to so-called second generation combined hormonal contraceptives containing levonorgestrel, norethisterone or norgestimate) but found some changes in the magnitude of the risks of VTE in all women (with and without hormonal contraceptive use). These revised estimates were included in the product information of products covered by the review. The review also appreciated that it may not always be possible to suspend use of a contraceptive in advance of prolonged immobilisation, major surgery, surgery to the legs or pelvis, neurosurgery, or major trauma. Consequently, the changes to the product information incorporated clear advice that antithrombotic treatment should be considered if the contraceptive has not been discontinued in these circumstances. Additionally, a user card and a prescriber checklist were also introduced for contraceptive users and prescribers respectively on the risks of blood clots, when these are increased, and symptoms to watch out for. These documents included a reminder to alert healthcare professionals including surgeons if surgery or immobilisation is planned or has recently occurred. We communicated the revised estimates of risk and on the new measures to reduce the risks to prescribers in 2014 through our newsletter Drug Safety Update1. In response to your request, we have reviewed the product information for all combined hormonal contraceptives and identified that the information for a small number of combined hormonal contraceptive products was not updated to include the new information as expected following the VTE review. We will request these be addressed as soon as possible. We would note however that the information currently provided for these products is less complete than the updated information described above rather than contradictory to it. Also, as highlighted in the response provided to you from NHS England, the risk factors for DVT and the link to oral contraception are not new or under-recognised issues. The prevention, diagnosis and management of DVT fall under the remit of clinical guidance. Risk factors, diagnosis and management of VTE are clearly set out in the NICE Pulmonary Embolism Clinical Knowledge Summary2. Guidance on risk assessment for VTE and on the use of antithrombotic preventative measures for patients undergoing surgery or who have experienced a trauma are addressed in NICE guideline (NG89)3: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. We welcome however the additional briefing that the Greater Manchester Integrated Care board have requested to focus on the learnings for clinicians from Rebekah’s death. I hope this has provided clarification on the range of risk minimisation measures in place for combined hormonal contraceptives. We will continue to keep the safety of these products under close review. Thank you for bringing this Regulation 28 report to our attention. I hope this information is helpful to you. Yours sincerely, Chief Safety Officer Medicines and Healthcare products Regulatory Agency References 1 Combined hormonal contraceptives and venous thromboembolism: review confirms risk is small - GOV.UK (www.gov.uk) 2 Risk factors | Background information | Pulmonary embolism | CKS | NICE 3 NICE guideline [NG89]: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism.
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