Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0303, written 4 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jun 2024 |
|---|---|
| Reference | 2024-0303 |
| Deceased | Susan Edwards |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Worcestershire Acute Hospitals NHS 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 THIS REPORT IS BEING SENT TO: , Chief Executive, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD; 1 CORONER I am David Donald William REID, HM Senior Coroner for Worcestershire. 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.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 17 October 2023 I commenced an investigation and opened an inquest into the death of Susan Lynne EDWARDS. The investigation concluded at the end of the inquest on 28 May 2024 The conclusion of the inquest was that Mrs. Edwards “Died as the result of a recognized complication of an accidental fall”. 4 CIRCUMSTANCES OF THE DEATH In answer to the questions “when, where and how did Mrs. Edwards come by her death?”, I recorded as follows: “On 7.10.23 Susan Edwards, who had fractured her left neck of femur in a fall in hospital in August 2023, and who had been admitted to Worcestershire Royal Hospital on 10.9.23 and treated for a likely urinary tract infection, suffered a sudden deterioration in her condition. Despite treatment, she declined and died in hospital later the same day. Post mortem examination has established that she died as the result of developing a large pulmonary embolus.” 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) On 19 September 2023 a Venous Thromboembolism Risk Assessment made clear that Mrs. Edwards should be provided with mechanical thromboprophylaxis. This instruction was not entered on Mrs. Edwards’ anticoagulation drug card, and Mrs. Edwards was not provided with any form of mechanical thromboprophylaxis between that date and her death 18 days later on 7 October 2023. No nurse or reviewing doctor picked up on this omission. 1 Although I was satisfied that, in this case, the provision of mechanical thromboprophylaxis would probably not have prevented Mrs. Edwards’ death, I am concerned that: (a) no system appears to be in place at Worcestershire Royal Hospital to ensure that such an instruction is carried out; and (b) as long as that remains the case, the lives of patients who require thromboprophylaxis during a hospital admission may be put at risk. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Executive of Worcestershire Acute Hospitals NHS Trust, 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 30 July 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: (a) , Mrs. Edwards’ daughter. 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 4 June 2024 David REID HM Senior Coroner for Worcestershire 2
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.
Ref: 30 July 2024 Mr David Reid HM Senior Coroner Worcestershire Coroners Court The Civic Martin’s Way Stourport on Severn Worcestershire Sent via email: Dear Mr Reid Re Regulation 28 Report to Prevent Future Deaths Please accept this letter in response to your Regulation 28 Report to Prevent Future Deaths received on the 7th June 2024, following the Inquest touching on the death of Mrs Susan Edwards. In your Regulation 28 report you identified the following matters of concern relating to the Worcestershire Acute Hospitals NHS Trust (WAHT). 1) On the 19th September 2023 a Venous Thromboembolism Risk Assessment made clear that Mrs. Edwards should be provided with mechanical thromboprophylaxis. This instruction was not entered on Mrs. Edwards’ anticoagulation drug card, and Mrs. Edwards was not provided with any form of mechanical thromboprophylaxis between that date and her death 18 days later on 7th October 2023. No nurse or reviewing doctor picked up on this omission. You further stated that although you were satisfied that, in this case, the provision of mechanical thromboprophylaxis would probably not have prevented Mrs. Edwards’ death, you were concerned that: a) No system appears to be in place at Worcestershire Royal Hospital to ensure that such an instruction is carried out; and b) As long as that remains the case, the lives of patients who require thromboprophylaxis during a hospital admission may be put at risk. Responding to the concerns raised; 1. We have focused on educating our staff in order to provide clear instructions around this area and will implement the following: o There will be a Lesson of the week around what constitutes both hosiery and mechanical prophylaxis, and it will be reiterated to staff that they must sign the prescription chart to confirm that this prophylaxis is on/in place. o Anti-coagulation nurses are going to provide some teaching to the junior doctor workforce to ensure their understanding of the practical impact of the different types of prophylaxis. o Anti-coagulation nurses have also offered to provide teaching to ward nurses. o Reminder of the above is to be verbalised across all areas via safety huddles. 2. Monitoring: o Checks of the prescription charts will be included on the matron’s audits (to check that the prescription has been signed as in/on) o Continue to audit via the matron’s audit already in place and divisional governance teams will continue their surveillance and escalate accordingly. 3. Long term plan is this will be on the electronic patient medical prescribing / administration system. I hope that the above addresses your concerns about the quality of our initial review. I have no representations in respect of publication of the Regulation 28 or this response by the Chief Coroner. I shall be grateful if you could kindly send a copy of my response to anyone to whom you copied your Regulation 28 report. Yours sincerely Chief Executive
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