Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0580, written 24 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Apr 2024 |
|---|---|
| Reference | 2024-0580 |
| Deceased | Derek Hand |
| Coroner | Anita Davies |
| Coroner area | Derby and Derbyshire |
| 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 Scottish Dental Clinical Effectiveness Programme 1 CORONER I am Anita Davies, Assistant Coroner Derby and Derbyshire 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 12 September 2023 I commenced an investigation into the death of Derek HAND aged 93. The investigation concluded at the end of the inquest on 24 April 2024. The conclusion of the inquest was that: Mr Hand died on 01 September 2023 at Chesterfield Royal Hospital. He was admitted on 26 July 2023 following a tooth extraction on the 25 July 2023, following which he experienced continued bleeding from the extraction site. Mr Hand was on Clopidogrel, an anti-platelet medication, and the tooth extraction was carried out in accordance with the guidance for patients on anti-platelet medication, however the site did not stop bleeding, despite sutures and packing of the site. An ambulance was called at approximately 1am on 26 July, Mr Hand lost consciousness when the ambulance crew was present and was transported to Chesterfield Royal Hospital where he was treated with a blood transfusion and high flow oxygen. His presentation initially improved and discharge was being planned during August. However, Mr Hand developed difficulties swallowing and subsequent aspiration pneumonia. His condition deteriorated at the end of August and he was placed on end of life care before passing away on 01 September 2023. 4 CIRCUMSTANCES OF THE DEATH Attended ED on 26/07/23 with history of tooth extraction earlier in the day, had bleeding, returned to dentist who stitched the area, bleeding stopped at that time, started bleeding again and called ambulance. He had an episode of seizure with ambulance crew that lasted for only a few seconds, self resolved with urinary incontinence. In ED he was given fluid for resuscitation. He had 2 episodes of seizures in ED, became unresponsive in ED after second episode., GCS dropped to 5/15, he was given IV leviteracetam(Keppra).His oxygen saturation was low, started on high flow oxygen, BP dropped to 42 systolic, red cells transfusion started and BP improved to 84/16. He became agitated and confused so he was given midazolam subcut. He continued to deteriorate with hypotension, bradycardia and low GCS so decision was made to start palliative care. EOL revoked on 28/7/23 due to clinical improvement. Chest Xray showed subtle reticular shadowing in right lower zone. He was treated with IV antibiotic and kept him Nil by mouth. NG tube was inserted on 02/8/23 for nutrition. Started oral trial on 08/08 as per SALT review along with NG feed. NG tube displaced on 10/08, new NG tune re-inserted. MRI brain was done on 16/8/23 to investigate cause for poor swallowing but no acute cause identified. On 30/8/23 Blood Culture showed streptococcus growth and started on Metronidazole in addition to ceftriaxone that he was already on. He continued to deteriorate so decision was made to proceed with EOL care after discussion Regulation 28 – After Inquest Document Template Updated 30/07/2021 with family. 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) The NHS Education for Scotland Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs states that for patients on Clopidogrel dental treatment can occur without interrupting medication. This is in contrast to, for example, patients on Warfarin, who are required to have an INR test prior to any procedure. Mr Hand's tooth extraction was performed as per the current guidance. As he was on Clopidogrel the procedure was carried out with no further checks being carried out as to his clotting function. Following the tooth extraction the site continued to bleed, to the extent that Mr Hand lost consciousness, required hospital admission and subsequently developed aspiration pneumonia. My concern is that as the current guidance does not require any further checks for patients on Clopidogrel prior to dental procedures there is a risk of other patients on Clopidogrel experiencing excess bleeding following dental procedures. It would be of assistance to know whether: a. Has any thought been given to requiring an INR test or any other form of blood test to detect a risk of excess bleeding for patients on Clopidogrel prior to dental procedures? b. If it has not, is there a reason for this? 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 June 19, 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 , solicitor to , Dentist. 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. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 24/04/2024 Anita DAVIES Assistant Coroner for Derby and Derbyshire 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.
Westport 102
West Port
Edinburgh EH3 9DN
Telephone: 0131 656 3200
Fax: 0131 656 3201
www.nes.scot.nhs.uk
Anita Davies, Assistant Coroner
Derby and Derbyshire
By email to:
Date: 30 October 2024
Email:
Dear Assistant Coroner,
Response from the Scottish Dental Clinical Effectiveness Programme, NHS Education
for Scotland, to the Regulation 28 Report received from Derby and Derbyshire
Coroner’s Office on 11 September 2024
Regarding the death of Derek Hand, the Assistant Coroner’s report noted the following
concern:
My concern is that as the current guidance does not require any further checks for patients
on Clopidogrel prior to dental procedures there is a risk of other patients on Clopidogrel
experiencing excess bleeding following dental procedures. It would be of assistance to
know whether:
a) Has any thought been given to requiring an INR test or any other form of blood test to
detect a risk of excess bleeding for patients on Clopidogrel prior to dental procedures?
b) If it has not, is there a reason for this?
Firstly, NHS Education for Scotland (NES) would like to extend its sincere sympathies to Mr
Hand’s wife and family.
The Scottish Dental Clinical Effectiveness Programme (SDCEP) is part of NES. Working in
collaboration with dental and medical clinical experts, SDCEP develops dental clinical
guidance that is based on the available evidence taking into consideration the benefits
versus harms, practicalities, and patient and practitioner views. Although developed within
NHS Scotland, SDCEP guidance is used across the UK to inform dental practice. As
guidance, the information presented does not override the healthcare professional’s right,
and duty, to make decisions appropriate to each patient, with the patient’s valid consent.
Therefore, clinical decisions will be based on the individual patient and their clinical history.
Chair:
Chief Executive:
In response to the queries from the Assistant Coroner, SDCEP can confirm that blood tests
to detect a risk of excess bleeding for patients taking clopidogrel or other antiplatelet drugs
were considered during the development of the Management of Dental Patients Taking
Anticoagulants or Antiplatelet Drugs guidance. Based on expert clinical opinion and
published advice, the guidance notes in Section 8 that “There is no suitable test equivalent
to the INR for measuring the antiplatelet effect of the various drugs that patients may be
taking.”
Clopidogrel acts by interfering with platelet activation, reducing the ability of platelets to
aggregate and form a clot. The INR (International Normalised Ratio) test, used to monitor
patients taking warfarin, measures the activation of coagulation factors and is not an
indicator of platelet function, so cannot be used to monitor the effects of clopidogrel.
In response to the Coroner’s Report, SDCEP has taken further clinical specialist advice which
confirms that it is still the case that there is no available blood test that would reliably
predict a risk of excessive bleeding for a patient taking clopidogrel.
The next review of the guidance is scheduled to commence in 2027. However, if SDCEP
becomes aware of any significant developments before the scheduled review, an earlier
review may be triggered. During the scheduled review, any new evidence or changes in
expert clinical opinion relating to the Assistant Coroner’s concerns will be considered to
check whether the situation has changed.
Yours sincerely.
Chief Executive, NHS Education for Scotland
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.