Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0600, written 5 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Nov 2024 |
|---|---|
| Reference | 2024-0600 |
| Deceased | Audrey Lambert |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: National Institute for Health and Care Excellence 1 CORONER I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester 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 28th May 2024 I commenced an investigation into the death of Audrey Margaret LAMBERT .The investigation concluded on the 14th October 2024 and the conclusion was one of narrative: Died from the complications of a deep vein thrombosis following an accidental fall and necessary surgery. The medical cause of death was 1a) Pulmonary Thromboembolism 1b) Deep Vein Thrombosis II) Sub trochanteric fracture right proximal femur (operated on) 4 CIRCUMSTANCES OF THE DEATH Audrey Margaret Lambert had an accidental fall at her home address on 25th March 2024. She was admitted to Stepping Hill Hospital and found to have a fracture of the right proximal femur. She was operated on. Post operatively she was prescribed 28 days course of heparin. Subsequently she was cared for at Brinnington Hall. Her mobility was significantly reduced and she required a hoist and the assistance of two to mobilise. On 28th May she was found unresponsive in bed. A post mortem found she had died from pulmonary thromboembolism due to a deep vein thrombosis. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The inquest heard evidence that prior to the fall and fracture Mrs Lambert 1 had been mobile. Following the operation her mobility was very limited. She was prescribed the standard heparin treatment post operatively. The inquest was told that it was recognised in her case that she had become very immobile since her fall. However the inquest was told that there was no national guidance that would assist clinicians in primary care in assessing whether they should consider prolonging the course of anti- coagulation prescribed in secondary care to reduce the ongoing risk of elderly immobile patients such as Mrs Lambert developing a fatal DVT in the community. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 31st December 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely on behalf of the family, who may find it useful or of interest. and 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 Alison Mutch HM Senior Coroner 05/11/2024 2 3
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 Redman Place
London
E20 1JQ
United Kingdom
+44 (0)300 323 0140
10 December 2024
Alison Mutch
HM Senior Coroner, Manchester South
Coroner’s Court
1 Mount Tabor Street
Stockport
SK1 3AG
By email to
Your reference:
Our reference:
Dear Ms Mutch
Re: Regulation 28 Prevention of Future Deaths Report in respect of Audrey Margaret
Lambert who died on 28 May 2024
I write in response to your regulation 28 report regarding the death of Mrs Audrey Lambert. I
would like to express my sincere condolences to Mrs Lambert’s family and loved ones.
We have reflected on the circumstances surrounding her death and senior clinical advisers
within our patient safety team have reviewed the concerns raised in your report.
I understand that the inquest was advised that Mrs Lambert had become very immobile
since her fall. The inquest was also advised that there was no national guidance that would
assist clinicians in primary care in assessing whether they should consider prolonging the
course of anticoagulation prescribed in secondary care to reduce the ongoing risk of elderly
immobile patients such as Mrs Lambert developing a fatal deep vein thrombosis (DVT) in the
community.
In the circumstances outlined in your report we believe that an assessment of the venous
thromboembolism (VTE) risk, balanced against the prophylaxis risk, should have been made
at discharge. Although our VTE guideline [NG89] does not give advice on starting VTE
prophylaxis de novo in the community, it does give advice on starting and continuing
pharmacological VTE prophylaxis after surgery (recommendation 1.11) and having a clear
discharge plan. Decisions on prophylaxis should be driven by the needs of the individual,
balancing the person's individual risk of VTE against their risk of bleeding when deciding
whether to offer pharmacological thromboprophylaxis to surgical and trauma patients
(recommendation 1.1.6).
If Mrs Lambert was not fully mobile on discharge, there is an expectation that this would be
considered in an assessment as part of the discharge plan, which might result in continued
VTE prophylaxis (either pharmacological or mechanical) as is recommended in our
guidance.
Both pharmacological and mechanical prophylaxis have well recognised side effects
(including a higher risk of intra and extracranial bleeding, higher drug costs and risks of renal
impairment especially in elderly patients with poor renal function). We therefore recommend
that a risk assessment should be made in conjunction with the patient before they are
prescribed (recommendation 1.2.2) and on discharge (recommendations 1.2.4 and 1.2.5).
It is difficult to provide more specific commentary without detailed information about Mrs
Lambert’s personal clinical circumstances, however our guidance does recommend in
several places the use of anti-embolism stockings or intermittent pneumatic compression,
which should be continued until the person no longer has significantly reduced mobility
relative to their normal or anticipated mobility.
I can confirm that we will review our guidance on stopping and starting VTE prophylaxis to
see if an update is warranted. The potential scope of this work is to be confirmed but it may
cover the management of people with immobility, if there is sufficient good quality evidence
on which to base recommendations.
Please do let me know if you require any further information and again, I offer my sincerest
condolences to Mrs Lambert’s family.
Your sincerely,
Chief Executive
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