Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0564, written 21 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Oct 2024 |
|---|---|
| Reference | 2024-0564 |
| Deceased | Brian Beer |
| Coroner | Peter Taheri |
| Coroner area | Suffolk |
| Category | Hospital Death (Clinical Procedures and medical management) 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 & Care Excellence (NICE)
1
CORONER
I am Peter TAHERI, Assistant Coroner for the coroner area of Suffolk
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 March 2024 I commenced an investigation into the death of Brian BEER aged 86.
The investigation concluded at the end of the inquest on 06 September 2024. The
conclusion of the inquest was that:
Narrative Conclusion - Brian Beer, an 86 year old gentleman, died due to a recognised
complication of necessary surgery on a fractured hip sustained in an unwitnessed fall. The
development of this complication was contributed to by the fact that local guidelines were
followed as to the cessation of prophylactic anti-coagulants after surgery, whereas evolving
international policy indicates that prophylaxis should be continued for a longer time period.
The death was also contributed to by frailty and advanced dementia, which both
contributed to the fall and compromised Mr Beer’s physiological reserve, such that his
capacity to recover from fracture, surgery and serious illness was compromised.
The medical cause of death was confirmed as:
1a Small Bowel Ischaemia
1b Superior Mesenteric Artery Thrombus
1c
2 Advanced Dementia, Left Hip Hemiarthroplasty 08.01.24 with VTE Prophylaxis for 28
Days
CIRCUMSTANCES OF THE DEATH
4
Brian Beer died peacefully at the West Suffolk Hospital on 1 March 2024. He died of small
bowel ischaemia, suffered due to a blood clot in an artery that provides blood to the small
bowel. Sustaining such a blood clot is a recognised complication of surgery on a hip
fracture. Mr Beer underwent a left femur head replacement on 8 January 2024, owing to a
hip fracture. This fracture was sustained in an unwitnessed fall at his care home, which was
contributed to by advanced dementia and frailty.
Although Mr Beer received prophylactic anti-coagulation after the hip surgery, in
accordance with and for the duration required by local hospital guidelines, the international
policy in this regard is evolving such that patients may be given anti-coagulation after
surgery for a longer period of time. The cessation of anti-coagulation in Mr Beer’s case at
the time it was ceased contributed to his death.
5
CORONER’S CONCERNS
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
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)
If NICE guidelines as to prophylactic anti-coagulation after surgery on a hip fracture do not
reflect the most up-to-date international learning, then there is a risk of future deaths
being contributed to by hospitals following NICE guidelines when a longer period of anti-
coagulation post-surgery would better protect them against recognised complications of the
surgery.
Explanation:
On referral of the case to the Coroner's Court:
, Medical Examiner, wrote:
"Given that he had no history of atrial fibrillation, ischaemic heart disease, peripheral
vascular disease or diabetes and atherosclerosis was not noted on the CT scan, there
appears to be a temporal relationship between the discontinuation
of the Tinzaparin and the superior mesenteric arterial thrombus causing the ischaemic
bowel. Local policy was followed. Internationally the policy is evolving ... patients have
longer on an anticoagulant after fractured neck of femur. Referral in light of a potential
indirect link between the discontinuation of the anticoagulation and the death."
In further communication with the Court in the course of the investigation,
wrote:
"His death is directly related to the thrombus within the superior mesenteric artery and his
only other co-morbidity is advanced dementia and frailty. It is likely that if
recommendations for fracture neck of femur is brought into line with the
recommendations for elective hip replacement surgery, he would not have had this
thrombus. Therefore, to the best of my knowledge, the cessation of the anti-coagulation did
make a material difference to his death."
The findings and conclusion of the Inquest were based on this evidence.
After the conclusion of the Inquest, I received further communication from
that further clarification, she stated that "venous thromboprophylaxis ('VTE') prophylaxis ...
was for the prevention of venous thrombosis and this gentleman died of an arterial
thrombus, therefore it is not clear what role the VTE prophylaxis plays in this, however
there is potentially a state of hypercoagulability following discontinuation of VTE
prophylaxis."
guidelines"; but she queried "whether the NICE guidelines (now 5 years old) need to
acknowledge this potential risk of hypercoagulability in the immobile, elderly patients on
discontinuation of the VTE prophylaxis and/or consideration of alternative agents or
regimes in this particular demographic, should it become evident that there is indeed this
risk."
went on to add that "our local guidelines are in line with NICE
. In
After the conclusion of the Inquest, I was also provided with an opinion from
, an expert haematologist.
advised that the guidance relating to venous
thrombosis is not relevant to an arterial clot - and prophylaxis is not given against arterial
clots. In her view, and that of two other expert practitioners in this area, the cessation of
VTE prophylaxis and the development of the arterial clot were not related.
added
that neither she, nor her two colleagues, are aware of an evolving international consensus
over the length of time for prophylaxis after a fractured neck of femur.
A communication was also then received from
fracture team are aware of some emerging early evidence regarding extending VTE
prophylaxis in such patients beyond the 4 week point."
, who added: "The Hip
Regulation 28 – After Inquest
Document Template Updated 30/07/2021
Bearing in mind
' evidence regarding evolving international policy, and
's indication of "some emerging early evidence" in this regard, in my opinion it is
appropriate to ensure that this concern is brought to the attention of NICE, to ensure that
appropriate consideration be given as to whether the national guidelines in this area require
revision, particularly bearing in mind that surgery on hip fractures is far from uncommon in
immobile and elderly, and therefore vulnerable, patients.
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 December 16, 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
West Suffolk Hospital
who may find it useful or of interest.
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
Dated: 21/10/2024
Peter TAHERI
Assistant Coroner for
Suffolk
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
10 December 2024
Mr Peter Taheri
Assistant Coroner for Suffolk
Coroners Service
Beacon House,
White House Road,
Ipswich,
Suffolk,
IP1 5PB
Sent via email:
Our ref:
Dear Mr Taheri,
I write in response to your regulation 28 report, dated 21 October 2024, regarding the sad
death of Mr Brian Beer. I would like to express my sincere condolences to Mr Beer’s family.
Following receipt of your report, senior clinical advisers within our patient safety team have
reviewed the concerns raised.
We note the comment in the report that Mr Beer died of an arterial thrombus. While we have
published guidance on venous thromboembolism [NG89] which covers assessing and
reducing the risk of (VTE or blood clots, including deep vein thrombosis and pulmonary
embolism) in people aged 16 and over in hospital, the guidance does not cover arterial
prophylaxis.
NG89 gives recommendations for anti-coagulation following fragility fractures of the pelvis,
hip and proximal femur (1.11.2-4) and following Elective hip replacement (1.11.5-7). These
state that people should be offered VTE prophylaxis for a month if the risk of VTE outweighs
the risk of bleeding. The guideline also states the clinicians should ‘Balance the person's
individual risk of VTE against their risk of bleeding when deciding whether to offer
pharmacological thromboprophylaxis to medical patients’ (1.1.6).
The decision whether to continue or discontinue anti-coagulation would be a matter for
clinical judgement based on careful assessment of an individual patient and their progress
after surgery.
In line with the expert haematologist and her colleagues, we are not aware of evolving
international consensus over the length of time for prophylaxis after a fractured neck of
femur and the possibility of mesenteric thrombosis. NICE will continue to monitor new
evidence in this area of practice. Any new evidence of sufficient quality will be considered as
part of a surveillance review, as described in our guidelines manual.
Your report has been shared with the surveillance team who will carry out this work.
Please do let me know if you require any further information and again, I offer my sincerest
condolences to Mr Beer’s family.
Yours sincerely,
Chief Executive
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