Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0484, written 28 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 | 28 Nov 2023 |
|---|---|
| Reference | 2023-0484 |
| Deceased | Ann Pearce |
| Coroner | Joanne Andrews |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Sussex NHS Foundation Trust |
| 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 – Chief Executive University Hospitals Sussex NHS Foundation Trust 1 CORONER I am Joanne ANDREWS, Area Coroner for the coroner area of West Sussex, Brighton and Hove 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 13 April 2022 I commenced an investigation into the death of Ann Dorothy PEARCE aged 61. The investigation concluded at the end of the inquest on 27 November 2023. The conclusion of the inquest was a narrative which stated: Ann Dorothy Pearce sustained a fracture of her tibial spine on 26 March 2022 having fallen from her bicycle in Burgess Hill that day. She was taken to the Princess Royal Hospital for treatment and discharged on 28 March 2022. On 1 April 2022 she became unwell at home and an ambulance attended and took her to the Princess Royal Hospital for treatment where she was diagnosed with a massive pulmonary embolism. She was treated but sadly died on 1 April 2022. 4 CIRCUMSTANCES OF THE DEATH Ann Dorothy Pearce was taken to the Princess Royal Hospital for treatment and was discharged on 28 March 2022. During her admission she was immobilised in a brace and on discharge was only partially weight bearing. The Venous Thromboembolism Prevention Policy of University Hospitals Sussex NHS Foundation Trust version 1.4 required that this should be undertaken on admission and reviewed on the daily ward round. No Venous Thromboembolism assessment was undertaken during her admission or on discharge. She became unwell at home on 1 April 2022 and was taken to hospital for treatment but sadly died from a massive pulmonary embolism Regulation 28 – After Inquest Document Template Updated 30/07/2021 that day. 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: Evidence at the inquest revealed that the Venous Thromboembolism Prevention Policy of University Hospitals Sussex NHS Foundation Trust version 1.4 did not make provision for assessment of risk to patients who attended hospital but were not admitted. There was no evidence of any other policy or procedure which did so. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 January 23, 2024. 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 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 28/11/2023 Joanne ANDREWS Area Coroner for West Sussex, Brighton and Hove 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.
,~1:kj University Hospitals Sussex NHS Foundation Trust University Hospitals Sussex NHS Foundation Trust Trust Headquarters Royal Sussex County Hospital Eastern Road Brighton BN2 5BE HM Area Coroner Ms Joanne Andrews Parkside Chart Way Horsham RH12 1XH Letter by email only 17 January 2024 Dear Ms Andrews Inquest into the death of Ann Dorothy Pearce Thank you for your letter of 28 November 2023, enclosing your formal report under Regulation 28 to Prevent Future Deaths. My heartfelt sympathy and condolences to Mrs Pearce's family. We have taken considerable actions and made extensive improvements to patient safety following Mrs Pearce's death and the inquest, and I will set these out below. We have developed a Trust policy for Thromboprophylaxis in Ambulatory Trauma Patients discharged from the Emergency Department. In addition, patient advice leaflets have been designed for clinicians to give to patients. The patient advice leaflets are as follows: Immobilisation advice leaflet Anticoagulation treatment with Dalteparin Anticoagulation treatment with Enoxaparin A Trust Theme of the Week message has been sent to all staff on 'VTE in lower limb injury and immobilisation' to ensure our clinical teams are up to date and this includes the top 3 'need to know' points as follows: 1. All patients will need baseline bloods (FBC, U&Es, LFTs and coagulation profile) within the last three months to aid prescribing of thromboprophylaxis. 2. If there are no contraindications, patients will need to be prescribed and discharged with 30 days of LMHW, or rivaroxaban if LMWH is contraindicated; if suspected Achilles tendon rupture then a 42 day course should be prescribed. 3. All patients will need advice leaflets on reducing the risk of VTE with lower limb treatment with Dalteparin or enoxaparin, or immobilisation and anticoagulation rivaroxaban. The key learning, patient leaflets, and new policy are being widely shared and discussed in department, team, and divisional safety huddles and meetings. Mrs Pearce's case has had an immense impact throughout the Trust and the learning has been disseminated widely as her legacy to improve patient safety. Once again, my sincere condolences to Mrs Pearce's family. I hope you are assured by the changes we have made. Yours sincerely, Chief Executive
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