Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0208, written 18 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Apr 2024 |
|---|---|
| Reference | 2024-0208 |
| Deceased | Michael Briggs |
| Coroner | Sophie Loman |
| Coroner area | Derby and Derbyshire |
| Category | Other 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 National Institute for HEALTH AND CARE EXCELLENCE 1 CORONER I am Sophie LOMAS, Assistant Coroner for the coroner area of Derby and Derbyshire 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 January 2023 I commenced an investigation into the death of Michael BRIGGS aged 79. The investigation concluded at the end of the inquest on 21 March 2024. 4 CIRCUMSTANCES OF THE DEATH On 7th November 2022 Michael Briggs consulted with his dentist as to undergoing dental extractions due to pain. He was advised to discuss the safety of such a procedure with his GP as he was taking anticoagulants. On 26th November he returned to his dentist and, having indicated to the dentist that there were no issues with him undergoing the procedure, he proceeded to have three extractions. The procedure was uneventful, and he returned home to recuperate. On 30th November 2022 Mr Briggs was admitted to A & E with a fever and reported a history of bleeding following the extraction. Blood cultures confirmed the presence of staphylococcus aureus and, as Mr Briggs had a bio-prosthetic aortic valve, it was suspected that he had developed infective endocarditis. The diagnosis was confirmed by Trans-oesophageal Echo on 14th December 2022 and he was treated with antibiotics. Despite treatment his condition continued to deteriorate. He was recognised as approaching the end of his life and sadly died at Royal Derby Hospital on 11th January 2023. The court heard evidence that infective endocarditis is a recognised complication of invasive dental procedures for those who have certain underlying health conditions such as valve replacements. For such patients the provision of antibiotic prophylaxis may reduce the risk of developing infective endocarditis. On the evidence before the court, it is not possible to determine whether prophylactic antibiotics would have made a difference to the outcome in Mr Brigg’s case. Narrative conclusion: Michael Briggs died due to recognised complications arising from a dental extraction procedure. 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: (brief summary of matters of concern) CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 The matters of concern arise in the context of patients who are at increased risk of infective endocarditis following dental procedures and whether such patients should be given antibiotic prophylaxis. At inquest the court heard evidence that there is limited guidance available for dentists in England and Wales on how to manage such patients. The evidence heard at inquest gives rise to the following matters of concern: The NICE guideline GC64 “Prophylaxis against infective endocarditis” states that • antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures. The guideline does not provide any implementation advice for dentists on how they should manage patients who are at an increased risk. • The Scottish Dental Clinical Effectiveness Programme (SDCEP) produced implementation advice in August 2018 entitled “Antibiotic Prophylaxis Against Infective Endocarditis”. The document contains a “NICE Statement of Endorsement” that the advice supports the implementation of recommendations in GC64. There is no reciprocal endorsement or mention of the SDCEP advice in GC64 and there does not appear to be any such implementation advice applicable to dentists in England and Wales. • In 2023 the European Society of Cariology (ESC) produced Clinical Practice Guidelines for the management of endocarditis which recommends antibiotic prophylaxis for high risk individuals. The court heard evidence that cardiologists in England and Wales are regularly following this guidance which conflicts with the 2016 NICE guideline. 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 May 31, 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 Royal Derby Hospital - Legal Services DENTIST 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. 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: 18/04/2024 CONTROLLED Regulation 28 – After Inquest Document Template Updated 30/07/2021 Sophie LOMAS Assistant Coroner for Derby and Derbyshire CONTROLLED 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.
2nd Floor
2 Redmond Place
London
E20 1JQ
United Kingdom
18 June 2024
Ms Sophie Lomas
Assistant Coroner – Derby and Derbyshire
St Katherine's House
St Mary's Wharf
Mansfield Road
Derby
DE1 3TQ
Dear Ms Lomas,
I write in response to your regulation 28 report of regarding the very sad death of Mr Michael Briggs. I
would like to express my sincere condolences to Mr Briggs’ family.
We have considered the circumstances in your letter regarding dental extraction and the prescribing
of antibiotics.
As you have noted in your report, in our guideline on prophylaxis against infective endocarditis:
antimicrobial prophylaxis against infective endocarditis in adults and children undergoing
interventional procedures [CG64] we do not routinely recommend antibiotic prophylaxis against
infective endocarditis (IE) for people undergoing dental procedures (recommendation 1.1.3).
The recommendation is worded as “do not routinely”, which emphasises NICE's standard advice
on healthcare professionals' responsibilities. Doctors and dentists should offer the most appropriate
treatment options, in consultation with their patients. In doing so, they should take account of the
recommendations in this guideline and the values and preferences of patients, and apply their clinical
judgement.
Therefore, if Mr Briggs’ clinical history and circumstances suggested to the dentist that antibiotics
might have been appropriate, to prescribe them would have been entirely in line with the discretion
supported by the guideline as outlined above.
When we publish our guidelines, we include tools and resources to support implementation. In terms
of the Scottish Dental Clinical Effectiveness Programme (SDCEP) implementation advice on antibiotic
prophylaxis against infective endocarditis, a link to this endorsed resource is included in the tools and
resources section for CG64.
In the 2015 review of CG64, the guideline committee agreed that current evidence was insufficient to
support the hypothesis that interventional procedures, including dental extraction, lead to the
development of infective endocarditis in people with pre-existing cardiac conditions. Furthermore, the
committee concluded that there is insufficient evidence to recommend prophylactic use of antibiotics
in those at risk of infective endocarditis undergoing interventional procedures, including dental
extraction. From the evidence examined, the committee were unable to establish whether or not
prophylaxis was effective.
The issue of conflicting information on the need for antibiotic prophylaxis being provided by
cardiologists, dental practitioners and hygienists was raised by the committee as a potential
significant problem and the committee discussed the importance of clear and consistent information
for patients and families and also that a balanced view of the lack of evidence indicating effectiveness
of prophylaxis for infective endocarditis as well as any potential harms of prophylaxis should be fully
explained to the person considering treatment. This will in turn allow the patient to make an informed
decision about continuing/discontinuing prophylaxis.
We have committed to review the current evidence relating to prophylaxis against infective
endocarditis this financial year and will determine whether any new information, studies or research
would support the case for a further update of existing NICE guidance.
Please do let me know if you require any further information and again, I offer my sincerest
condolences to Mr Briggs’ family.
Yours sincerely,
Chief Executive
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