Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0372, written 6 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Oct 2023 |
|---|---|
| Reference | 2023-0372 |
| Deceased | Adam Stuyvesant |
| Coroner | Ian Singleton |
| Coroner area | Wiltshire and Swindon |
| Category | Road (Highways Safety) related deaths · Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Private and confidential Ian Singleton, Esq His Majesty’s Area Coroner for Wiltshire Marlborough Road Swindon SN3 6BB 15/11/2023 Dear Mr Singleton Re: Coroner’s Regulation 28 Report We write in response to the Regulation 28 Prevention of Future Deaths Report, raising concerns about the circumstances which led to the death of the late Mr Adam Stuyvesant. I was very sorry to hear of the sad death of Mr Stuyvesant. I was also concerned to learn of your matters of concern which are repeated here: 1) The wearing of a black boot can lead to lower limb immobility and the possibility of a restriction in the “calf pump function” which can lead to deep vein thrombosis. 2) The Deep Vein Thrombosis (DVT) risk assessment in use in the Emergency Department at the Great Western Hospital made no provision to take account of immobilisation when considering whether anti- clotting medication should be prescribed. 3) That without taking account the immobility, as part of the DVT risk assessment, further patients may not be prescribed anti-clotting medication and as a result develop DVT, resulting in death from pulmonary embolus. In December 2022 a patient safety review into Adam’s case was presented at the Incident Review Meeting, as a result an action plan was generated with a focus to improve the performance of the DVT risk assessments and provide assurance around the issuing of patient information via written communication (patient information leaflet). To enhance this the Emergency Department reassessed the recommendations from the 2018-19 Royal College of Emergency Medicine (RCEM) national quality improvement project (QIP) on Venous Thromboembolism (VTE) risk management, the department has also reviewed and taken appropriate action in line with the recommendations suggested at the end of the inquest. 1 The Trust guideline for Venous Thromboembolic event follows both RCEM and National Institute of Clinical Excellence (NICE) guidance. There has been a strict emphasis on these guidelines to be followed by all the clinicians who deal with the patients requiring a black orthopaedic boot for trauma. The Trust has reviewed the assessment again following the regulation 28 and are confident that the current VTE risk assessment is fit for purpose. As part of the review our local VTE risk assessment was compared to the Plymouth Scoring system, a nationally recognised standard, to assess whether the appropriate treatment is being given to patients and we confirm it is in line with this standard. To guide staff, the Trust's policy was reviewed and updated to indicate that patients who receive a black boot to assist with mobility but have significant reductions in their mobility will require a VTE assessment. VTE education and training is now a part of the local induction process for all junior doctors when they commence working in the emergency department. There has been an increased focus on the patient information leaflets and the VTE risk assessment checklist in the department for patients with a black boot and these have since been relocated to the area where the black boots are stored. This is to emphasise the importance of completing the correct documentation for VTE risk assessments for patient requiring a black boot. There has also been a MEMO reminder sent to all Emergency Department staff reminding them that they need to complete risk assessments for any patients who are wearing lower limb casts or black boot. Information leaflets regarding mobility of a patient wearing a black boot has been revised. We have communicated to all staff within the Emergency Department the requirement to ensure that both verbal and written patient information is provided and recorded as complete within the health care records. We will continue to monitor the effectiveness of the changes by way of spot check audits within the department, these results will be shared at Divisional Governance meetings and appropriate actions taken as required. Finally, I would like to reiterate my sincerest condolences to Mr Stuyvesant’s family and apologise for the distress this process may have caused. Yours sincerely Chief Executive Copy to: CQC 2
H.M. Coroner for Wiltshire & Swindon David Ridley Senior Coroner Ian Singleton Area Coroner Nicholas Rheinberg Assistant Coroner Wiltshire & Swindon Coroner's Court 26 Endless Street Salisbury Wiltshire SP11DP Date: 6 October 2023 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Great Western Hospital, Marlborough Road, Swindon 1 CORONER I am Ian Singleton, Area Coroner for Wiltshire and Swindon 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. http://www. legislation .gov. u k/u kpga/2009/25/sch ed u le/5/pa rag ra ph/7 http:/Lwww. legislation.gov.uk/uksi/2013/1629/part/7 / made 3 INVESTIGATION and INQUEST On 2 September 2022 I commenced an investigation into the death of Adam Connelly STUYVESANT. The investigation concluded at the end of the inquest on the 6 October 2023. The conclusion of the inquest was: Narrative Conclusion On the 17 August 2022 Adam Connolly Stuyvesant was involved in a minor, single vehicle road traffic collision, on the Marlborough Road at Pewsey Wiltshire. He was admitted to The Great Western Hospital Emergency Department, Marlborough Road, Swindon, where in addition to minor injuries he was diagnosed with an avulsion fracture from the lateral malleolus in the left ankle. Adam was given a plastic boot to wear which immobilized the ankle. At that time, the DVT risk assessment had it been carried out would only have taken account of Adam's size, not the ankle immobility, which carried a risk of deep vein thrombosis. On the 22 August 2022 Adam collapsed at Unit 31 Blackworth Industrial Estate, Highworth, Swindon and despite best efforts at resuscitation, died. The post mortem confirmed that death was due to the immobilisation of the left ankle allowing a deep vein thrombosis to develop which led to pulmonary embolus. la Pulmonary Embolus lb Deep Vein Thrombosis le Lower Limb Immobilisation Secondary to Injury after Road Traffic Accident II 4 CIRCUMSTANCES OF THE DEATH See Box 3 above 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:- (1) The wearing of a plastic boot can lead to lower limb immobility and the possibility of a restriction in the "calf pump function" which can lead to deep vein thrombosis. (2) The DVT risk assessment in use in the Emergency Department at The Great Western Hospital, made no provision to take account of the immobilisation when considering whether anti-clotting medication should be prescribed. (3) That without taking account of the immobility, as part of the DVT risk assessment, further patients may not be prescribed anti-clotting medication and as a result develop DVT, resulting in death from pulmonary embolus. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, The Great Western Hospital, 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 5 December 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 the family of Adam Connolly Stuyvesant. 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 6 October 2023 - Signature Ian Singleton, Area Coroner for Wiltshire and Swindon
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