Alan Kinsbury

Your ref: 

Karen Henderson 
Assistant Coroner 
c/o Lyn Ralfe 
Parkside Chart Way, Horsham, RH12 1XH 

   16th August 2024 

Dear Dr Henderson, 

Re: Inquest into the death of Dr Alan William Kingsbury 

Thank  you  for  your  letter  of  5th  July  2024  and  the  notification  of  Regulation  28:  REPORT  TO 

PREVENT  FUTURE  DEATHS  for  our  attention,  dated  8/7/24.  We  were  sad  to  hear  of  the 
circumstances of Dr Kingsbury’s passing, and wish his family our sincerest condolences on their 

loss. 

The British Society for Dermatological Surgery (BSDS) was not in any way aware of or involved 

in  the  inquest  arising  from  the  death  of  Dr  Kingsbury  and  was  not  invited  to  provide  any 

evidence  (written  or  oral)  prior  to  receipt  of  the  Regulation  28  report.  The  first  the  BSDS  was 

made aware of the death was via the Regulation 28 report, received on 5 July 2024. The BSDS 
has  not  had  sight  of  the  Coroner’s  bundle  or  any  other  evidence  arising  from  the  inquest 

investigation itself. This makes it very difficult to be able to comment on the matters raised. The 

BSDS  will  attempt  to  respond  to  the  concerns  raised  to  the  best  of  its  ability  without  full 

disclosure and knowledge of the issues explored during the inquest.  

BSDS  were  also  uncertain  which  points  we  were  expected  to  respond  to,  and  thus  sought 

further clarification from your office, with the reply being we should respond to items 5.1, 5.2 and 
5.3 ‘if appropriate’.  

We  will  therefore  respond  below  primarily  to  the  ‘Matter  of  concern’  raised  in  point  5.1  of  the 

Regulation 28 notice received. However, we would like to offer some comments relating to point 
5.2,  which  is  within  our  purview  and  a  current  focus  of  our  Society’s  educational  activities. 

Without  access  to  the  full  details  of  this  case,  we  simply  cannot  comment  on  elements  of 

surgical technique used (5.3).  

British Society for Dermatological Surgery, Willan House, 4 Fitzroy Square, London W1T 5HQ 

Registered Charity No.  800213 

 
  
 
 
 
 
 
 
 
 
 
 5.1 BSDS (British Society of [sic] Dermatological Surgery) Guidelines on Anti-  

thrombotics and skin surgery for dermatological excisions in the community.  

Our  guidelines  are  not  aimed  at  surgery  in  ‘the  community’.  The  majority  of  Dermatological 

Surgeons perform surgery in a secondary care hospital setting, in acute hospitals, or sometimes 

in more peripheral hospitals. There may be other guidance more appropriate for community use 

(e.g. surgery in primary care). This is relevant as the range of facilities, surgical expertise, and 

experience of supporting staff is typically more advanced in a hospital setting. 

The  guidance  itself  is  composed  of  a  14  page  text  document,  and  accompanying  risk 
stratification table, and a summary flowchart for quick use1. The flowchart cannot contain all the 
same information so clearly states ‘see accompanying full text guideline document for details’. 

This  guidance  is  designed  to  be  used  by  someone  with  appropriate  dermatological  training  in 

lesion  diagnosis  and  treatment  and  is  intended  to  support  colleagues  in their shared  decision-

making  with  patients,  in  gauging  the  right  balance  between  the  risk  of  a  bleeding  event  from 

surgery, the risk from a thrombotic event, the risk and waste from unnecessary rescheduling of 

surgery causing delays to skin cancer diagnosis or treatment. 

We highlight several highly relevant statements contained in the guidance below: 

Page 2 Para 2 
‘Skin  surgery  varies  in  complexity  and  bleeding  risk,  as  do  the  characteristics  of  individual 

patients,  so  temporary  cessation  of  anti-thrombotic  therapy  is  sometimes  advisable  on  the 
balance of risks.’  

Page 2 Para 3 
‘This  is  a  guide  only  and  clinical  judgement  should  ultimately  determine  the  degree  of  risk, 
particularly for complex patients. Advice from a multidisciplinary team may also be helpful.’  

Page 2 Para 4 & 5 
‘Many surgeons already avoid stopping any anti-thrombotic drugs pre-operatively. However, the 

safety of this approach does depend on careful case selection, patient preparation and support, 

and  the  choice  of  therapy.  Many  high  risk  bleeding  procedures  could  potentially  be  avoided 

altogether.  

 
 
 
 
 
 
 
 Individual  patients  vary  in  their  attitudes  towards  balancing  the  risk  of  post-operative  bleeding 
versus  a  thrombotic  event.  Achieving  the  patient’s  informed  consent  is  crucial  in  decision-
making for complex skin surgery, as recently redefined by the UK supreme court ‘Montgomery’ 
ruling.’  

‘Bleeding  can  also  lead  to  falls  or  in-patient  admission  in  the  elderly.  Serious  morbidity  or 

mortality is extremely unlikely. Risk factors can be additive (e.g. multiple drugs + repair type + 

age >65).  

Page 2 Para 7-8; Page 3 Para 1 

Clearly  meticulous  operative  technique  is  always  required  to  minimise  the  risk,  but  bleeding 

problems  can  still  occur.  Excessive  bleeding  during  surgery  usually  responds  to  more 

meticulous electrosurgery or vessel tying, followed by a pressure dressing and patient rest and 

elevation  where  possible.  However  some  agents  can  cause  prolonged  oozing  after  the  local 

anaesthetic (LA) wears off, or for several days post-operatively, even if excellent haemostasis is 

achieved  intra-operatively.  Therefore  reducing  this  risk  by  postponing  surgery,  altering  the 

choice of procedure or repair, or sometimes withholding medications may be prudent. It is also 

crucial to pay greater attention to post-operative follow-up, considering home support, and day 
case vs overnight in- patient stay, especially for the elderly.’ 

Page 3 Para 2  

Weigh up the risk factors and obtain informed consent for a plan agreed with the patient, other 
relevant physicians and surgeons, and the patient's family or advocate.’  

Page 3 Final Para 

‘Consider postponing surgery until off clopidogrel if possible (e.g. surgery for BCC), especially if 
taking as part of dual- antiplatelet regimen.’  

‘Combinations of multiple drugs’ 

Page 5 Para 3 
Potential to increase the risk of bleeding significantly.

If procedure has high bleeding risk, delay 

where  possible  until  patient  on  monotherapy  (e.g.  for  patients  on  dual  anti-platelet  treatment 

British Society for Dermatological Surgery, Willan House, 4 Fitzroy Square, London W1T 5HQ 

Registered Charity No.  800213 

 
 
 
 
 
 
 
 following percutaneous coronary intervention). If urgent, consider taking advice on modification 
of regimen, or changing the procedure.’  

The guidance also gives a range of advice on how to minimise or treat excessive bleeding intra- 

and post-operatively, and stresses the importance of ensuring appropriate home support in case 

of bleeding problems. 

The  guidance  and  flowchart  places  particular  emphasis  on  assessing  patient  specific  risk 

factors,  in  addition  to  medication  that  may  increase  bleeding  risk.  The  guidance  also  stresses 

the  importance  of  assessing  the specific risk  of thrombosis  versus the risk  of  bleeding  for  any 

individual  patient,  and  ensuring  a  decision  is  reached  with  the  patient  by  shared  decision-

making as to whether to stop or continue medication.  

We do not know the details of the indication(s) for Dr Kingsbury’s anti-platelet medications, so 

cannot comment on the balance of risks in his case. The guidance highlights the high risk of 

bleeding for patients taking combinations of multiple anti-platelet medications, and encourages 

discussion with the prescribing doctor about the potential cessation of at least one of these if 

possible, or consideration of postponement of the procedure to reduce bleeding risk, if the skin 

lesion is low risk.  

There is a discrepancy in the Regulation 28 report as to the skin lesion diagnosis. Part 1c for the 
medical cause of death is recorded as ‘Fall secondary to anaemia, secondary to bleeding chest 
wall lesion (excised squamous cell cancer 19.10.23)’, but the narrative conclusion states the 
lesion  removed  was  ‘squamous  cell  carcinoma  in  situ’.  The  distinction  is  important  as  it 

impacts on management and prognosis. Squamous cell carcinoma carries a risk of metastasis 

and  often  requires  urgent  treatment.  However  squamous  cell  carcinoma  in  situ  is  pre-invasive 

and can often be treated with more superficial procedures such as curettage and cauterisation, 

cryotherapy, or non-surgical (e.g. topical) treatment, although we recognise excision biopsy can 

be required to rule out invasive squamous cell carcinoma. We have highlighted this discrepancy 
to  your  office  and  we  received  a  response  that  the  index  skin  lesion  was  a  presumed  ‘rapidly 
growing  squamous  cell  carcinoma’  although  there  is  no  histological  confirmation  as  Dr 

Kingsbury died before a report was issued.   

 
 
 
 
 
 
 Depending  on  the  full  details  of this  case,  the  flowchart  suggests  at  least  one  higher  bleeding 
risk patient factor: ‘age >65’. Primary closure on a compressible site is low risk in our risk table 

in  isolation,  but  the  guidance  makes  it  clear  that  this  must  be  interpreted  with  other  patient 
factors.  The  report  mentions  ‘the  excision  was  larger  than  expected  with  some  difficulty  in 
obtaining primary closure.’ This is not the description of a typical low risk procedure. As such we 

would classify this scenario as high risk. The flowchart advice is therefore as follows: 

'Stop  any  unintended  prescription. Consider  postponing  until  off  drug Combinations:  Consider 
stopping clopidogrel or 1 of the drugs (take advice)’ 

The  flowchart,  like the text  document,  also makes  a range  of  recommendations to  consider to 

reduce the bleeding risk: 

‘- Postpone  

- Choose safer surgical procedure (or radiotherapy or non-surgical)  

- Increase support or admit patient  

- Elevate and compress post-op  

- Change operative setting (e.g. to improve equipment access, nursing support or more suitable 

operator)  
- Give tranexamic acid (oral or infiltrated)’ 

The  report  into the  prevention  of  future  deaths  states  that the  BSDS  guidance  is  ‘insufficiently 

robust  to  reflect  bleeding  potential  from  a  myriad  of  factors  including  the  condition  of  the  skin 
being excised, the position of the lesion and the underlying frailty and medical co-morbidities…’  

We are not aware of any dermatological surgery evidence that ‘the condition of the skin being 
excised’  or  ‘extremely  fragile  skin’  should  be  factored  into  a  guideline  on  anti-thrombotics  and 

skin  surgery.  The  guideline  explicitly  mentions  various  body  sites  that  can  affect  bleeding  risk 

such  as  vascular  sites  on  the  face  and  non  compressible  areas  such  as  the  eye.  There  is 

recognition in the guideline that age >65 years is a high-risk patient factor.  

The  guideline  is  not  intended  to  be  an  exhaustive  medical  reference  to  cover  all  aspects  of 

patient assessment that would usually be expected in routine medical care by an appropriately 

skilled medical professional.  

British Society for Dermatological Surgery, Willan House, 4 Fitzroy Square, London W1T 5HQ 

Registered Charity No.  800213 

 
 
 
 
 
 
 
 5.2 The lack of a Preoperative assessment and advanced consent  

Page 2 Para 4 & 5 

As per our own guidelines we have no disagreement about obtaining proper informed consent: 
‘Individual  patients  vary in  their  attitudes towards  balancing  the risk  of  post-operative bleeding 
versus  a  thrombotic  event.  Achieving  the  patient’s  informed  consent  is  crucial  in  decision-
making for complex skin surgery, as recently redefined by the UK supreme court ‘Montgomery’ 
ruling.’  

The  extra  challenges  posed  by  achieving  informed  consent  for  same-day  ‘see  and  treat’  type 

procedures for skin cancer diagnosis and treatment are well known to our speciality. There can 

be  benefits  from  this  approach,  in  shortening  the  time  to  diagnosis  and  curative  treatment, 

reducing  travel  and  carer  inconvenience,  and  healthcare  costs.  The  taking  of  anti-thrombotic 

medication  does  not  necessarily  mandate  the  avoidance  of  a  procedure  at  the  initial 

consultation  visit,  but  clearly  requires  appropriate  information  to  be  provided  in  advance, 

adequate  time  for  the  clinician  to  assess  the  risks  (and  any  steps  that  might  be  possible  to 

reduce  those  risks),  adequate  time  for  the  patient  to  consider  the  risk  and  benefits  and  weigh 

the  decision,  and  appropriate  documentation  of  the  shared  decision-making  process.  Consent 

should  be  a  two  stage  process  with  an  appropriate  period  of  reflection,  depending  on  case 

complexity.  The  complexity  of  the  decision  and  the  amount  of  time  required  will  vary  between 

patients,  so  services  offering  same-day  surgery  must  also  be  able  to  offer  surgery  at  an 

appropriate later date if necessary. Many departments do offer such services safely. We aim to 

teach these  principals  in  our  courses  and  online learning,  and  a relevant journal  publication  is 

currently in press. 

We would like to draw your attention to the extensive training and educational activities that the 

British Society for Dermatological Surgery provides on these topics for members and the wider 

profession  in  our  popular  online  educational  meetings  and  in-person  courses  for  hundreds  of 
doctors  and  nurses  each  year.2  We  also  explicitly  cover  the  complexities  of  pre-operative 

assessment, the management of frailty and anti-thrombotic medication, and informed consent in 
our virtual learning modules that complement our guidance:3 

-Pre-Operative Care for Medically-Complex Patients 

-Consent and Medicolegal 

 
 
 
 
 
 In  summary,  in  response  to  the  matter  of  concern  raised  in  5.1  of  the  regulation  28  report, 
regarding  “position  of  the  lesion”;  “underlying  frailty”  and  “medical  co-morbidities”,  the  BSDS 

guidelines  on  antithrombotics  and  skin  surgery  does  make  specific  mention  to  consider 

anatomical  location  along  with  patient  factors  including  frailty  due  to  age  and  medical  co-
morbidities. As  the  BSDS  is  unaware  of  any  published  evidence  on  “the  condition  of  the  skin” 

impacting on bleeding following cutaneous surgery, this is not included in the guideline.  

Having  carefully  considered  the  Coroner’s  concerns  in  the  Regulation  28  report,  it  is  the 
Society’s  view  that  the  guidelines  referred  to  are  sufficiently  robust  as  currently  drafted  and 

based on clinical expertise and published evidence. We hope we have adequately responded to 

or addressed all your concerns raised in the Regulation 28 report. Thank you for giving us the 

opportunity to contribute to this investigation. 

Yours sincerely, 

BSDS President and Consultant Dermatological Surgeon 

On behalf of The Executive Committee of the British Society for Dermatological Surgery 

References: 

1  British  Society  for  Dermatological  Surgery  (BSDS)  guidance  on  antithrombotics  and  skin  surgery  2023; 

https://bsds.org.uk/resources/bsds-bad-guidelines/ 
2 https://bsds.org.uk/events/ 
3  British  Society  for  Dermatological  Surgery  (BSDS)  &  British  Association  of  Dermatologists  British  College  of 

Dermatology Virtual Learning Modules; https://learning.bcd.org.uk 

British Society for Dermatological Surgery, Willan House, 4 Fitzroy Square, London W1T 5HQ 

Registered Charity No.  800213

Patient: Alan KINGSBURY (02 Apr 1938) / Coroner ref: Our ref: 

Date: 25 Sep 2024 

Sussex & Surrey Community Dermatology Service 
Administration Office 
51 Chesswood Road 
Worthing  
West Sussex 
BN11 2AA 
Working in Partnership with 
University Hospitals Sussex NHS Foundation Trust 

Dear Ms Henderson, 

Re: Response to Regulation 28: Report to Prevent Future Deaths  

Patient: Alan KINGSBURY (02 Apr 1938) 

I  am  writing  on  behalf  of  Sussex  Community  Dermatology  Service  (SCDS)  in  response  to  the 
Regulation 28 notice arising from the Inquest into the death of Dr Alan William Kingsbury. 

The coroner identified three areas of concern. 

1.  The  British  Society  of  Dermatological  Surgery  (BSDS)  Guidelines  on  anti-

thrombotic and skin surgery in the community.  

•  This  concern  has  been  addressed  directly  to  the  BSDS  so  SCDS  will  not 
comment  on this  but  await the  response  from the BSDS  and  any  change to  the 
current guidance 

2.  The lack of a pre-operative assessment and advanced consent.  

•  Currently in the UK patients with a suspected skin cancer may be seen at a F2F 
appointment  prior  to  having  surgery  scheduled,  they  may  be  offered  surgical 
excision  at  the  first  appointment,  or  they  may  be  assessed  remotely  vie 
teledermatology  and  then  booked  directly  for  surgery.  Most  UK  dermatology 
departments  will  utilise a combination  of  the  above,  all  of  which are  appropriate 
depending on individual patient circumstances. Patients who are at higher risk of 
post-operative complications and in particular post-operative haemorrhage (such 
as  patients  on  anticoagulants,  elderly  patients,  large  tumours)  should  be 
identified and measures put in place to manage the risk. 

▪ Action to be taken: 

SCDS  will  ensure  that  its  policies  are  sufficiently  robust  to  be  able  to 
identify  at  risk  patients  at  the  time  of  1st  encounter  and  ensure  that  risk 
mitigation measures are in place. To achieve this, we will do the following: 
-  Perform  a  thorough  documented  preoperative  assessment  to 

assess risk of complications associated with skin surgery. 

-  Ensure  advanced  consent  and  scheduling  of  the  procedure  to 

allow adjustment of anticoagulation as appropriate. 

Page 1 of 2 

 
 
 
 
                                                                                                                                  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Patient: Alan KINGSBURY (02 Apr 1938) / Coroner ref: Our ref: 

-  Follow  up-to-date  guidance  regarding  anticoagulants  in  skin 

surgery. 

-  Always ensuring a favourable risk: benefit profile 

Most  of  the  above  is  already  in  place,  however  we  await  any  revised  guidance 
from  the  BSDS  in  response  to  the  coroners  concerns  and  will  integrate  any 
amended guidance into the policy 

3.  Guidance as to the appropriateness of surgical technique for wound closure 

•  Our  clinicians  are  all  very  experienced  in  skin  surgery  and  we  routinely  monitor 
various aspects of their practice including postoperative infections, postoperative 
bleeding and wound dehiscence as part of our ongoing clinical governance using 
RADAR software. Our complication rates are very low and comparable to all our 
local  NHS  trust  services.  Surgical  excision  wounds  are  routinely  closed  with  a 
deep layer of self-dissolving subcutaneous sutures and cutaneous sutures. 

▪ Action to be taken: 

We  will  use  this  case  to  highlight  the  importance  of  ensuring  adequate 
deep  closure  of  wounds  especially  when  dealing  with  patients  at  higher 
risk of postoperative bleeding and wound dehiscence. 

This response has been communicated to our clinical staff. 

Yours sincerely, 

Clinical Director 
Consultant in Dermatology and Cutaneous Surgery 
Sussex & Surrey Community Dermatology Service 

Page 2 of 2