Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2024-0368, written 6 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Dec 2023 |
|---|---|
| Reference | 2024-0368 |
| Deceased | Margaret Heal |
| Coroner | James Thompson |
| Coroner area | Durham & Darlington |
| Category | Other related deaths |
| Organisation named | County Durham and Darlington NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 1 CORONER I am James E THOMPSON, Assistant Coroner for the coroner area of County Durham and Darlington 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 25/07/2022 14:17an investigation was commenced into the death of Margaret HEAL 30/07/1935 00:00:00. The investigation concluded at the end of the inquest on 06/12/2023 00:00. The conclusion of the inquest was that Margaret Heal died on 12th July at her home, thromboembolism which had caused by a deep venous thrombosis. This is a natural disease running its full course and resulting in her death. She had stopped taking her anti- coagulant medication on medical advice 10 days prior to her death to undergo surgery. She did not resume this medication after it. It is unclear on the evidence if she was unaware of the need to resume the medication or she chose not to resume the medication.. from a massive pulmonary 4 CIRCUMSTANCES OF THE DEATH Margaret Heal died on 12th July at her home, from a massive pulmonary thromboembolism which had caused by a deep venous thrombosis. This is a natural disease running its full course and resulting in her death. She had stopped taking her anti-coagulant medication on medical advice 10 days prior to her death to undergo surgery. She did not resume this medication after it. It is unclear on the evidence if she was unaware of the need to resume the medication or she chose not to resume the medication. 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) During the course of the inquest it became apparent there was no evidence to show the deceased had been provided with a document instructing her to resume her anti coagulation. Whilst this requirement is set out in the Trust's procedures, no evidence was found it had taken place. No document was found in Mrs Heal's home at the time of her death. It is of concern that Mrs Heal was an 86 year old lady living alone after her discharge from hospital. Is there more that can be done to ensure patients particularly who are vulnerable and / or elderly are given advice regarding recommencement of drugs in a Regulation 28 – After Inquest Document Template Updated 30/07/2021 manner, to ensure as far possible, they are aware of the need to recommence their medication. 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 January 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to who may find it useful or of interest. 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: 06/12/2023 James E THOMPSON Assistant Coroner for County Durham and Darlington Regulation 28 – After Inquest Document Template Updated 30/07/2021
Executive Corridor Darlington Memorial Hospital Hollyhurst Road Darlington, DL3 6HX E-mail: Our Ref: 031ST January 2024 Mr James E Thompson, HM Coroner, 4th Floor Civic Centre, Crook, County Durham, DL15 9ES Dear Mr Thompson, Re: Margaret Heal I am writing in response to Regulation 28 Report to Prevent Future Deaths, which you issued to County Durham & Darlington NHS Foundation Trust on 14th December 2023. As you are aware, in this instance the Trust were not represented at the inquest. You raised one matter of concern that creates the risk of other deaths; as outlined below: Is there more that can be done to ensure patients particularly who are vulnerable and/or elderly are given advice regarding recommencement of drugs in a manner, ensure as far possible, they are aware of the need to recommence their medication. Therefore we would like to take this opportunity to explain our current process and our review of Mrs Heal’s patient record; to see if this provides the reassurance that you seek. Current Endoscopy Process for stopping and restarting medication All patients who are pre-assessed are given advice and written information at the pre- assessment appointment, the pre-assessment team follow the BSG guidelines. The decision to restart the medication is made at the point of completing the procedure but the PA nurses will give an estimate at the time of pre-assessment of how long medications would be withheld in line with current recommendations. Not all patients are pre-assessed prior to endoscopy, the need for pre-assessment being determined by the procedure to be performed. For patients who are not pre-assessed, which was the case with Mrs Heal, then clinicians would usually give relevant advice in clinic regarding when to stop anticoagulation (the need to withhold apixaban 2 days prior to the procedure was recorded in the notes from Mrs Heal’s clinic attendance). Our procedure taking anticoagulants/antiplatelets to contact the department, by telephone, for advice, this advice is given by a member of nursing staff following the BSG guidance. This information is included (PIL) also ask patients who are specific leaflets in the patient information leaflet to ensure that patients who are not pre-assessed are able to access appropriate advice. Upon completion of an endoscopic procedure the discharging nurse goes through the results, follow up and recommendations with the patient (and usually with a family member too) prior to discharge. Information on starting medications is reinforced at that point and a copy of the report is provided to the patient which includes this information in writing. It should be noted that Mrs Heal's notes confirm that she received a copy of the endoscopy report and verbal information at the point of discharge. Current processes also include sending an email copy of the procedural report to the patient’s GP surgery within 24 hours of discharge. It is our opinion that the process described above is a robust way of communicating post procedure instructions to our patients, if however, you have continued concerns then we would welcome the opportunity for a senior member of our patient safety team to meet with you to better understand the issues raised in the inquest, and to discuss the improvements that you feel may be necessary to address the issues identified. I hope that you find the actions taken by the Trust to be adequate to address the issues that you have raised, but please do not hesitate to contact me if you require further information. Yours sincerely Executive Director of Nursing Executive Medical Director cc. , CEO , Associate Director of Nursing, Patient Safety , Associate Medical Director for Patient Safety
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