Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0033, written 17 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jan 2025 |
|---|---|
| Reference | 2025-0033 |
| Deceased | Vauna Leeming |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Worcestershire Acute Hospitals NHS Trust |
| 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 THIS REPORT IS BEING SENT TO: , Chief Executive, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD; 1 CORONER I am David Donald William REID, HM Senior Coroner for Worcestershire. 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 3 April 2024 I commenced an investigation and opened an inquest into the death of Vauna LEEMING. The investigation concluded at the end of the inquest on 15 January 2025. The conclusion of the inquest was that Mrs. Leeming “died from natural causes, to which a recent fractured neck of femur and surgical repair thereof contributed”. 4 CIRCUMSTANCES OF THE DEATH In answer to the questions “when, where and how did Mrs. Leeming come by her death?”, I recorded as follows: “On 6.2.24 Vauna Leeming was admitted to Worcestershire Royal Hospital after suffering an accidental fall at home, and was found to have sustained a fractured right neck of femur. She underwent surgery to repair the fracture on 8.2.24, from which she initially made a satisfactory recovery. However, on 23.3.24 her condition deteriorated, and she tested positive for Covid-19. She went on to suffer a pulmonary embolism and, despite treatment, declined and died in hospital on 25.3.24.” 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. – 1) Following Mrs. Leeming’s surgery on 8.2.24, measures were put in place to prevent the formation of a deep vein thrombosis and/or pulmonary embolism. Those measures were prescriptions for anticoagulation medication ( Enoxaparin ) and for compression stockings. The inquest heard evidence that over the 46 days between the surgery and Mrs. Leeming’s death: (a) on 2 days ( 10 and 13.2.24 ) no documentation was completed by nurses to show whether Enoxaparin had in fact been administered; and 1 2) (b) on a total of 15 days ( including 5 consecutive days in one week ) no documentation was completed by nurses to show whether compression stockings had been fitted and were being worn; It was of particular concern that for 5 consecutive days, no nurse had noticed or raised with a senior colleague that the prescription charts had not been completed to show that compression stockings had been fitted. This suggests either that there is little understanding of a nurse’s professional duty to report such omissions, or that the practice of not checking and completing such important documentation is commonplace; 3) The inquest heard evidence that whilst in its induction to new nurse employees, the Trust emphasises the importance of completing documentation, it is still heavily reliant on agency nurses, for whom it cannot be expected to provide such an induction; I am concerned that the evidence in this case highlights that there is still insufficient awareness among employed and agency nurses at the Trust’s hospitals of their professional duty: (a) to complete important documentation such as prescription charts; and (b) to report any omissions in the completion of such documentation to a 4) senior colleague. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Executive of Worcestershire Acute Hospitals NHS Trust, 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 14 March 2025. 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: (a) (b) ( Mrs. Leeming’s husband and next of kin ); , National Medical Director, NHS England. 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 17 January 2025 David REID HM Senior Coroner for Worcestershire 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.
Our ref: 26 February 2025 Dear Mr Reid Chief Executive Worcester Royal Hospital Charles Hastings Way Worcester WR5 1DD Tel: Email: Fax: Re Regulation 28 Report to Prevent Future Deaths Please accept this letter in response to your Regulation 28 Report to Prevent Future Deaths received on the 15th January 2025, following the Inquest on the death of Vauna Leeming. In your Regulation 28 report, you identified the following matters of concern relating to the Worcestershire Acute Hospitals NHS Trust (WAHT). 1) You were concerned that there is still insufficient awareness among employed and agency nurses at the Trust of their professional duty: (a) to complete important documentation such as prescription charts and (b) to report any omissions in the completion of such documentation to a senior colleague The Chief Medical Officer (CMO) requested an Extra-Ordinary VTE meeting to discuss Ms Leemings case, the concerns raised by yourself, and to assess our own level of assurance around compliance relating to VTE prophylaxis. There were a number of measures agreed including: • It was agreed and confirmed that mechanical thromboprophylaxis (TEDS/compression stockings) remain the best option if the patient was unable to receive pharmacological thromboprophylaxis (such as Enoxaparin) • To increase the monitoring of VTE compliance via our Improving Safety Action Group (ISAG), chaired by the Chief Nursing Officer/CMO. Chair: Chief Executive: The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process. In response to your specific concerns listed above please find below the actions the trust have taken: 1a) i. ii. iii. 1b) i. Ward managers and Matrons, in their daily safety huddles and team meetings, are reinforcing the direction that staff must sign prescription charts. To update and re-circulate the lesson of the week Trust-wide on mechanical thromboprophylaxis and the importance of signing prescriptions The CMO will write to the digital team creating the electronic medical prescribing charts, formally requesting that they ensure that the new charts meet all requirements, prior to being launched (e.g. prescribing of TEDS) There is a question (see below) on the weekly quality checks that are completed by ward managers and matrons, this is not always utilised if the question was not applicable to that patient (as not every patient on every ward is audited). This would be an opportunity for ward managers to highlight and escalate accordingly any gaps or omissions. QUESTION: Has mechanical VTE prophylaxis been prescribed (TED stockings/boot) QUESTION: If prescribed, has the mechanical VTE prophylaxis been signed on the chart as 'in place'? ii. iii. Therefore, each division will undertake local regular audits, to check compliance with signing prescription charts Divisions will provide monthly VTE compliance reports to the Improving Safety Action Group (ISAG) Please let me know if you require any further information. Yours sincerely, Chief Executive Chair: Chief Executive: The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process.
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