Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0016, written 9 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Jan 2024 |
|---|---|
| Reference | 2024-0016 |
| Deceased | Karena Wicking |
| Coroner | Nicholas Shaw |
| Coroner area | Cumbria |
| 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.
Kally Cheema LLB | Senior Coroner | Cumbria
Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
9 January 2024
THIS REPORT IS BEING SENT TO:
Intergrated Care
CORONER
I am Dr Nicholas Shaw - HM Assistant for Cumbria
CORONER’S LEGAL POWERS
- CEO of North Cumbria
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.
1
2
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
INVESTIGATION and INQUEST
On 16 February 2023 I commenced an investigation into the death of Karena WICKINGS.
The investigation concluded at the end of the inquest . The conclusion of the inquest was
Death from complications arising from an essential surgical procedure.
3
1a Pulmonary Embolism
1b
1c
II
CIRCUMSTANCES OF THE DEATH
4
Karena Wickings - aged 58 died in her home in Brampton, Cumbria on 5th February
2023. She had been admitted to hospital two months previously for laparoscopic surgery
to remove a screening detected colonic cancer. She had a prolonged admission due to
multiple postoperative complications requiring further surgeries. Throughout her
admission she was given anticoagulant prophylaxis in the form of enoxaparin. Her clinical
condition was improving and it seemed as if the cancer had been fully removed but at the
time of discharge her mobility remained significantly restricted. Anticoagulant prophylaxis
stopped when she left the hospital and it is unclear if ongoing indication was considered.
It is more likely than not that the lack of ongoing prophylaxis led to the formation of
thrombosis in her left leg and her death due to pulmonary embolism.
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. –
[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The surgical mortality review conducted after Karena's does not seem to have
considered the role that anticoagulation may have played. I understand trust guidelines
suggest it continues until 5-7 days or until the patient regains full mobility. I was told many
surgeons will extend this to 28 days. Karena was past the 28 day period but still had
significant restriction at the time of discharge. A few years ago I heard a very similar case
which occurred at a different health trust. The purpose of this report is to suggest that
discharge planning might have a prompt to consider possible ongoing anticoagulant
prophylaxis in patients who leave the hospital but have not yet regained full mobility.
(2)
(3)
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and the
wider trust have the power to take such action.
YOUR RESPONSE
5
6
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 6th March 2024. I, the coroner, may extend the period.
7
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.
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons [NAMES]
8
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 January 2024
9
Signature
Dr Nicholas Shaw HM Assistant Coroner for
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.
Version 10 Coroner’s ref: Trust ref: North Cumbria Integrated Care’s Regulation 28 Updated Action Plan Concerning the Inquest into the death of Karena Wickings Dated: 01/05/2024 Concern 1 The surgical mortality conducted after Karena’s death does not seem to have considered the role that anticoagulation might have played. Recommendation 1: Target Date: Update: Action: Lead: Business Intelligence Team to notify Collaborative of community deaths within 30 days of elective surgery to allow for clear escalation and timely review of patient’s care. April 2024 the information Share received Business from Intelligence with the Mortality Surveillance Group and agree how case reviews will occur within the Collaborative. Collaborative Nurse’s Lead Critical within Care, Specialist and Surgical Care Surgical the alongside Mortality Surveillance Group as Trust wide 03/04/2024 listed to be discussed at the next mortality meeting the 15/04/2024 discussed at mortality meeting. Plan Business for Intelligence Team to send monthly reports to the Surgical Lead Collaborative Nurse and this will be shared via email to all Lead Nurses and then at discussed be Directorate level. A documented process for action which should be taken, once a is notification of coronial case Head of Legal Services To provide a clear instruction to the recipients around what is required from them once April 2024 Complete. Email sent to Legal Services Team 23/04/2024: Page 1 of 4 Version 10 received from the Legal Team to intended recipients. notified of a coronial case to cross reference if the case review has already been undertaken. Training to be provided by the Legal Team to Collaborative to increase knowledge base and awareness of process. Inquest Templates SLegal Services NCIC7 - GUIDANCE TEMPLATESInquestsEmail Templates.msg to Guidance Due service pressures it is hoped that a programme will be delivered by the end of 2024. is in place and already provided when information requesting from the Collaborative and and witnesses, there to is create a Trust specific inquest guide. intention Concern 2 Evidence heard that within this case Trust and NICE guidance was followed, but no evidence of consideration to extending the VTE prophylaxis on discharge Recommendation 2: Update the Pharmacological VTE Prophylaxis in Adult Medical and Surgical Patients Guidelines to include advice on discharge and documenting VTE risk. Recommendation 3: the nursing discharge Amend checklist to document the ongoing plan for VTE prophylaxis at the time to ensure patient of discharge, Lead: Clinical Director General for Surgery and Medicine Action: Review latest NICE guidance and update Trust Guidelines. Target Date: April 2024 Lead: Matron Action: Share Regulation 28 with all Matrons for awareness. Target Date: April 2024 Update: 03/04/2024 Guideline with the Clinical Director for General Surgery and being is updated. currently Update: Email sent to Matrons 03/04/2024: Page 2 of 4 Version 10 information advice and management plan if for pharmacological VTE. Recommendation 4: VTE assessment at the time of discharge to be documented on the summary, discharge electronic providing an update on actions taken to reduce this risk and any further actions required. Lead: Surgical Collaborative Chair Care Regulation 28 sharing with CLN.msg 03/04/2024 Meeting with held with Chief Nursing Information Officer to discuss implementation. Target Date: June 2024 Update: Liaise with Digital Systems to update the system to include VTE on discharge the nursing checklist. in Audit discharge checklist to ensure compliance with checklist. Action: Provide training and guidance around the assessing and documentation of VTE at time of discharge. Amend discharge summary. plan Describe of clear ownership should a patient be discharged on pharmacological VTE. To be reviewed in line with Medical Discharge Summary Improvement Project. Page 3 of 4 Version 10 Recommendation 5: Amend the ward round proforma to include daily review of VTE in place and plan for discharge with regards to VTE. Lead: Surgical Care Collaborative Lead Nurse Concern 3 Target Date: April 2024 with Action: surgical Discuss speciality the ward round proforma and understand how best to prompt for a daily VTE review and also a clear plan for discharge around VTE risk. Update: 03/04/2024 Draft version completed but awaiting final sign off on new to clinical ensure all information is captured. guideline Karena was experiencing significantly reduced mobility at the time of discharge. Recommendation 6: Appropriate action reduced mobility physiotherapy team ongoing rehabilitation. Action: To share good practice within department. taken around from the to support Lead: Head Physiotherapy of Target Date: February 2024 Update: Completed 03/04/2024 as confirmed via email: confirmation of sharing with AHP.msg Page 4 of 4
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