Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0463, written 22 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Nov 2023 |
|---|---|
| Reference | 2023-0463 |
| Deceased | David Lewsey |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Information Classification: CONTROLLED NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 1 CORONER , Old Bridge Surgery, Looe I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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 21/11/23, I concluded an inquest into the death of David John Lewsey who died on 15/12/22 at the age of 68. . The medical cause of death was recorded as: 1a) Pulmonary thromboembolism 1b) Deep vein thrombosis of left calf 1c) Knee replacement operation I recorded a Narrative Conclusion that Mr Lewsey died from a known complication of an elective surgical procedure. 4 CIRCUMSTANCES OF THE DEATH Mr Lewsey was a 68-year-old man who underwent a left knee replacement on 29/11/22. Upon discharge, he was prescribed with two weeks of aspirin to reduce the risk of developing a clot and codeine for pain relief. The codeine caused Mr Lewsey to become constipated. On 15/12/22, he rang the surgery for treatment to relieve his constipation. In the first call with reception staff, he reported a ‘terrible, terrible pain in his side.’ This information was not passed on to the Advanced Nurse Practitioner (ANP) who returned Mr Lewsey’s call. In his first call with the ANP, Mr Lewsey said that his left side hurt like he had a stitch and that he felt pain when he breathed in. I found as fact that it was more likely than not that this was caused by a developing pulmonary embolus. No consideration was given to excluding a PE as a possible cause of the 1 Information Classification: CONTROLLED pain. It is more likely than not that the PE was caused by a DVT in his leg that developed following Mr Lewsey’s immobility after his knee operation. Mr Lewsey collapsed later that evening at his home address and could not be resuscitated. 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: - Evidence was heard at inquest that if the concern of a terrible pain in his side, reported in Mr Lewsy’s first telephone call to reception staff, had been passed on to the ANP, the initial discussion between Mr Lewsey and the ANP may have started down a different path. It was recognised that the doctors and nurses dealing with duty calls work under pressure, and it was felt that ensuring accurate and complete information was passed to them may reduce that pressure and facilitate the provision of a better service to patients. - The inquest also heard that reception staff had some training to raise a red flag if pain in the ‘chest’ was reported to them. Mr Lewsey said he had pain in his ‘side’ but the precise location of that pain was not explored further. While it was said in evidence that, typically, a PE will present with pleuritic or chest pain, it was noted that NICE guidance includes abdomen pain. You may wish to reflect on whether additional training is required for all staff on how to manage complaints of pain in the chest or abdomen particularly in patients who have recently undergone procedures that may have left them relatively immobile and at an increased risk of developing a DVT. 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 19/1/24. 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. 2 Information Classification: CONTROLLED 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 Mr Lewsey; - - legal representaitves; legal representatives. I am also under a duty to send the Chief Coroner and above IPs 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 [DATE] [SIGNED BY CORONER] 22/11/23 3
Information Classification: CONTROLLED NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. National Institute for Clinical Excellence (NICE) 1 CORONER I am Andrew Cox, the Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 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 21/11/23, I concluded an inquest into the death of David John Lewsey who died on 15/12/22 at the age of 68. . The medical cause of death was recorded as: 1a) Pulmonary thromboembolism 1b) Deep vein thrombosis of left calf 1c) Knee replacement operation I recorded a Narrative Conclusion that Mr Lewsey died from a known complication of an elective surgical procedure. 4 CIRCUMSTANCES OF THE DEATH Mr Lewsey was a 68-year-old man who underwent an elective left knee replacement on 29/11/22. , the consultant orthopaedic surgeon who performed the procedure, confirmed that his default position was to prescribe low molecular weight heparin for the initial period in hospital and then to prescribe a fortnight's worth of aspirin. It was established in evidence that the NICE guidance (NICE 89 – VTE in over 16s – reducing the risk of hospital acquired DVT or PE) suggested at paragraph 1.11.8 that LMWH should be used with TED stockings until discharge. It was view that the foot pumps provided in hospital, Flowtrons, were superior to TED stockings and, in this regard, the 1 Information Classification: CONTROLLED consultant felt the NICE guidance needed to be updated. It is understood that there may be other compression systems or VTE prevention pumps that it may also be appropriate to consider. Mr Lewsey collapsed on the evening of 15/12/22 at his home address and could not be resuscitated. 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. – The relevant NICE guidance may need to be updated to reflect the use of LMWH with products that assist with VTE prevention other than TED stockings. 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 19/1/24. 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 Mr Lewsey; - The legal representatives of I am also under a duty to send the Chief Coroner and above IPs 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 2 Information Classification: CONTROLLED 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 [DATE] [SIGNED BY CORONER] 22.11.23 3
2 responses 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.
2nd Floor
2 Redmond Place
London
E20 1JQ
United Kingdom
6 February 2024
Andrew Cox
H.M. Coroner’s Office
The New Lodge
Newquay Rd
Penmount
Truro
Cornwall
TR4 9AA
Dear Mr Cox,
I write in response to your regulation 28 report regarding the very sad death of David John
Lewsey. I would like to express my sincerest condolences to his family.
We have considered the circumstances surrounding Mr Lewsey’s death and I have
addressed below the matter of concern directed to NICE.
In developing our guideline on venous thromboembolism in over 16s: reducing the risk of
hospital-acquired deep vein thrombosis or pulmonary embolism [NG89], the committee
considered a number of pharmacological and mechanical prophylaxis options, including foot
impulse devices or foot pumps (FID) and intermittent pneumatic compression devices
(IPCD). The committee considered these interventions on their own and in different
combinations.
The trial data for all mechanical prophylaxis options showed they were used for longer
durations than in current clinical practice, where early mobilisation is encouraged, and so the
committee felt that it may not be possible to replicate the efficacy levels reported.
Furthermore, as it was not possible to include any side effects for mechanical prophylaxis
options in the analysis the committee determined that their cost-effectiveness might be over-
estimated.
More generally, the committee noted there was uncertainty around the relative effectiveness
estimates for different prophylaxis strategies and so the committee opted to give a choice of
prophylaxis options, noting that some people may have contraindications.
The committee’s consideration of the evidence underlying recommendations for
thromboprophylaxis in elective knee replacement surgery are presented in chapter 27 of
volume 2 of the full guideline.
When exercising their judgment, professionals and practitioners are expected to take NICE
guidelines fully into account, alongside the individual needs, preferences and values of their
patients or the people using their service. It is not mandatory to apply the recommendations,
and the guideline does not override the responsibility to make decisions appropriate to the
circumstances of the individual, in consultation with them and their families and carers or
guardian, or preclude other treatment options from being offered.
Your report has been shared with our guideline surveillance team for further consideration
when the guideline is reviewed.
I hope that you find this information helpful.
Yours sincerely,
Chief executive
Page | 2
Information Classification: CONTROLLED 14th December 2023 Mr A Cox HM Coroner for Cornwall and the Isles of Scilly Cornwall Coroner’s Service Pydar House Pydar Street Truro Cornwall TR1 1XU Dear Mr Cox Thank you for your letter of 22nd November 2023 and the regulation 28 report. I note that you have highlighted some areas of concern. I reviewed the call recording of the initial call to reception. The whole Practice team then attended a training afternoon on Wednesday 6th December. As a major part of the training afternoon, we held a session on telephone triage and call handling. During the session we specifically highlighted the process of flagging calls for concern at the stage that the reception team are adding them to the duty call list. We discussed the types of calls that may cause concern and the importance of providing as much detail as possible in the free text “reason for the call” area. The entire team of clinicians who may be involved in triaging calls from the duty call list discussed and reflected upon the presentation of pulmonary emboli, including the rare occurrence of abdominal rather than chest pain. We also discussed other presentations of emergency medical and surgical problems in patients who have recently had a stay in hospital. Our intention would be to audit in future the fullness of details recorded by reception staff for calls added to the duty list and will present the results at a future training session within the next six months. Information Classification: CONTROLLED I would be grateful if you could let me know if the actions taken (and proposed) fulfil the requirements of the regulation 28 notice? Yours sincerely
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