Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0450, written 13 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Aug 2024 |
|---|---|
| Reference | 2024-0450 |
| Deceased | Jeffrey Marshall |
| Coroner | Anna Loxton |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Jeffrey MARSHALL
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
•
•
, Chief Executive, NHS England
, Chief Executive, National Institute for Health and
Care Excellence
1 CORONER
Ms Anna Loxton, HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3
INVESTIGATION and INQUEST
The inquest into the death of Jeffrey MARSHALL was opened on 4th
January 2024. Evidence was heard and the inquest was concluded on 13th
June 2024.
Mr Marshall died at St Peter’s Hospital in Chertsey on 13th December
2023, aged 72 years.
I found the medical cause of death to be:
1a. Ischaemic Stroke
1b. Thrombosis of Basilar Artery
1c. Atherosclerosis of Basilar Artery
2. Previous Subdural Haematoma; Hypertension; Diabetes Mellitus;
Atrial Fibrillation; Cessation of Anticoagulation Therapy
I found that whilst the cause of death was natural, it was contributed to
by the withholding of anticoagulation therapy over the previous 47 days
prior to death. Mr Marshall had sustained a subdural haematoma in a fall
on 21st October 2023, following which his anticoagulation therapy was
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withheld pending further CT scan to check that this had resolved before
recommencing anticoagulation.
Whilst a further CT scan took place on 8th November 2023, this was not
reported until 3rd December 2023, and Mr Marshall’s GP was informed by
the Hospital that his anticoagulation should be recommenced on 6th
December 2023. Mr Marshall suffered an ischaemic stroke on 7th
December 2023 as a result of thrombosis of the basilar artery, of which he
was at increased risk due to the withholding of anticoagulation therapy.
He deteriorated until his death.
I heard evidence from a Stroke Consultant at Ashford and St Peter’s
Hospitals NHS Foundation Trust that the half-life of Direct Oral
anticoagulants is short and therefore the benefit of its risk reduction for
thrombus is lost within a short period of time, placing the patient at high
risk of stroke. She detailed that whilst it is standard protocol to withhold
anticoagulation following a head injury, there is no national guidance
(e.g. from the National Institute for Health and Care Excellence) to assist
in determining when anticoagulation should be recommenced. There is
the withholding of
also no guidance
anticoagulation and the risks/benefits of this with patients, to enable
them to make an informed decision as to when to recommence
anticoagulation in this scenario.
for clinicians
to discuss
I recorded a narrative conclusion of Natural Causes contributed to by
withholding of anticoagulation over 47 days following subdural
haematoma.
4 CIRCUMSTANCES OF THE DEATH
Mr Marshall died from an ischaemic stroke at St Peter’s Hospital in Chertsey on
13th December 2023.
He had suffered a fall whilst exiting a car on 21st October 2023, in which he
sustained an acute subdural haematoma. His anticoagulation therapy of
Edoxaban, prescribed for atrial fibrillation and permanent pacemaker, was
withheld in accordance with NICE guidance.
Neurosurgeons at St George’s Hospital in Tooting gave advice and reiterated
the need to withhold anticoagulation and to monitor the bleed via further CT
scan the following day, and again two weeks thereafter.
The last scan on 8th November 2023 revealed that the haematoma had resolved,
but this was requested on a routine basis with a reporting time of 28 days. It was
therefore reported on Sunday 3rd December, and Mr Marshall’s GP was advised
that anticoagulation could be restarted on 6th December 2023.
Mr Marshall suffered a sudden loss of consciousness at home on the evening of
7th December 2023 and was admitted to St Peter’s Hospital, where he was found
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to have suffered a Basilar Artery Thrombosis and Basilar Territory Infarction.
His anticoagulation had been withheld for 47 days on a background of atrial
fibrillation and permanent pacemaker, increasing his risk of thrombus
development.
Mr Marshall’s stroke was not survivable and he died on 13th December 2023.
5 CORONER’S CONCERNS
The MATTERS OF CONCERN are:
- Mr Marshall was prescribed anticoagulation (Edoxaban) to
mitigate his increased risk of developing thrombus due to atrial
fibrillation and a permanent pacemaker;
- Anticoagulation was withheld following a traumatic head injury,
in accordance with NICE guidance;
- There is no national guidance to assist clinicians in determining
when anticoagulation should be recommenced in this scenario, nor
any recommendation for clinicians to discuss the risks and benefits
of withholding anticoagulation with patients to enable them to
make an
to recommence
anticoagulation.
informed decision as
to when
Consideration should be given to whether any steps can be taken to
address the above concerns.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the following:
1. See names in paragraph 1 above
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2.
3. Ashford & St Peter’s Hospitals NHS Foundation Trust
4. The Chief Coroner
In addition to this report, I am 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 at the time of your response, about the release or
the publication of your response by the Chief Coroner.
Signed:
ANNA LOXTON
DATED this 13th day of August 2023
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2 responses 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.
Ms Anna Loxton
HM Assistant Coroner for Surrey
Station Approach
Woking
GU22 7AP
National Director of Patient Safety
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
6 November 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Jeffrey Marshall who died
on 13 December 2023
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 13
August 2024 concerning the death of Jeffrey Marshall on 13 December 2023. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Jeffrey’s family and loved ones. NHS England are
keen to assure the family and the Coroner that the concerns raised about Jeffrey’s
care have been listened to and reflected upon.
I am grateful for the further time granted to respond to respond to your Report, and I
apologise for any anguish this delay may have caused to Jeffrey’s family or friends. I
realise that responses to Coroner Reports can form part of the important process of
family and friends coming to terms with what has happened to their loved ones and
appreciate this will have been an incredibly difficult time for them.
Your Report raised the concern that there is no national guidance to assist clinicians
in determining when anticoagulation should be recommenced following a traumatic
head injury, nor any recommendation for clinicians to discuss the risks and benefits of
withholding anticoagulation with their patients.
I note, in addition to NHS England, that your Report has been addressed to the
National Institute for Health and Care Excellence (NICE). They are the appropriate
organisation to respond to the Coroner’s concerns, as the provider of the relevant
clinical guidance. NHS England will carefully review NICE’s response to the Coroner
in due course, and consider whether any resultant actions are required from us.
It should however be noted that there will need to be a significant degree of
individualised care and decision-making in cases such as Jeffrey’s. There will need to
be careful consideration of the risks of atrial fibrillation stroke versus the risk of
precipitating bleeding (dependent on different patient factors), and that this could
provide challenge to producing specific guidance on this issue.
It is difficult for NHS England to provide more detailed comments on the quality of care
delivered to Jeffrey based on the information in your Report. However, we do note that
there looks to have been a significant delay between the second CT scan being taken
on 8 November 2023 and the results being reported on 3 December 2023, and that it
is possible this could have delayed any decisions on whether to restart Jeffrey’s
anticoagulation medication. My colleagues in the South East region have been asked
to gather further information on this, as part of our Regulation 28 assurance processes.
I would also like to provide further assurances on national NHS England work taking
place around the Reports to Prevent Future Deaths. All reports received are discussed
by the Regulation 28 Working Group, comprising Regional Medical Directors, and
other clinical and quality colleagues from across the regions. This ensures that key
learnings and insights around events, such as the sad death of Jeffrey, are shared
across the NHS at both a national and regional level and helps us to pay close
attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Director of Patient Safety
2nd Floor
2 Redman Place
London
E20 1JQ
United Kingdom
3 October 2024
Ms Anna Loxton
HM Assistant Coroner for Surrey
Sent via email:
Our reference:
Dear Ms Loxton,
Re: Regulation 28 Prevention of Future Deaths Report in respect of Jeffrey Marshall
I write in response to your regulation 28 report dated 13 August 2024 regarding the sad death
of Jeffrey Marshall. I would like to express my sincere condolences to Mr Marshall’s family.
We have reflected on the circumstances surrounding Mr Marshall’s death and the concerns
raised in your report. We note your concerns that Mr Marshall’s anticoagulation medication
was withheld following a traumatic head injury, in accordance with NICE guidance, and that
there is no national guidance to assist clinicians in determining when anticoagulation should
be recommenced in this scenario, nor any recommendation for clinicians to discuss the risks
and benefits of withholding anticoagulation with patients to enable them to make an informed
decision as to when to recommence anticoagulation.
Following receipt of your report, senior clinical advisers within our patient safety team have
reviewed the concerns raised. They have outlined that there are no specific NICE
recommendations that cover the question of when to restart antithrombotic therapies in
patients following traumatic intracranial haemorrhage or anything that would help to inform a
conversation with the patient about this. The NICE guideline, Head injury: assessment and
early management [NG232], gives guidance on when to perform a CT scan and on referral
and admission, but not on withholding, substituting or restarting anticoagulants in this
situation.
In the NICE guideline, venous thromboembolism in over 16s: reducing the risk of hospital-
acquired deep vein thrombosis or pulmonary embolism [NG89], in relation to cranial surgery,
it states; ‘Do not offer pharmacological VTE prophylaxis to people with ruptured cranial
vascular malformations (for example, brain aneurysms) or people with intracranial
haemorrhage (spontaneous or traumatic) until the lesion has been secured or the condition
has stabilised. (emphasis, recommendation 1.12.10) and, in relation to major trauma
‘Consider pharmacological VTE prophylaxis for people with serious or major trauma as soon
as possible after the risk assessment when the risk of VTE outweighs the risk of bleeding’.
Although these situations are not the same as those of Mr Marshall, the inference is towards
not restarting anticoagulants until there has been a risk assessment.
Our senior clinical advisers have outlined that there is also various external literature on this
subject, however this area is complex, as the risk to patients will depend on the baseline risk
from the underlying reason that they were on anticoagulants in the first place, the severity and
cause (traumatic or spontaneous) of the bleeding episode itself, whether any reversal agents
were used and any immobility after the acute event and in the recovery phase. Unfortunately,
there is very little research evidence on which guidelines relevant to this complex decision
could be based, and a high degree of clinical judgement is required in each individual person’s
case.
We have considered whether there is enough consensus opinion or any expert guidelines that
inform (or in this case, should have informed) clinicians in the management of Mr
Marshall. Our clinical advisers’ review suggests that current guidelines do not address the
issue of when to restart anticoagulants after traumatic intracranial haemorrhage.
In summary, we agree that this specific question is not well covered by current guidance. NICE
will consider the issues raised through our guidelines surveillance team and process, and
update or issue new guidance recommendations, accordingly, depending on the outcome of
these considerations. We will also discuss with relevant specialist societies the possibility of
reaching a consensus statement on this subject.
I hope this response is helpful in confirming the actions that we will take as a result of your
report relating to Mr Marshall and would like to reiterate my condolences to his family.
Yours sincerely,
Chief Executive
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