Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, written 15 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Sep 2018 |
|---|---|
| Deceased | Marian Grant |
| Coroner | Darren Salter |
| Coroner area | Oxfordshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Dr Bruno Holthof, Chief Executive, Oxford University Hospitals NHS
Foundation Trust
CORONER
lam Mr D M Salter, HM Senior Coroner for Oxfordshire.
CORONER’S LEGAL POWERS
| 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.
INVESTIGATION AND INQUEST
On 5 September 2018 | conducted the inquest into the death of Marian Grant at
Oxford Coroner's Court. My Conclusion was one of ‘Accident’ and | made the
following finding:
‘Marian Grant tripped and fell at Magdalen Park, Oxford at approximately 16.30
hours on 14 April 2018. She was assessed but not given DVT prophylaxis and
succumbed to a Pulmonary Embolism at the beginning of the operation on 16 April
2018 to replace the fractured hip.’
The Trust were legally represented at the inquest. In addition to written evidence
submitted by the Trust, there was oral evidence from
(Consultant Anaesthetist), Zi (Consultant Trauma and Orthopaedic
Surgeon) and IEEE concerning the RCA Investigation Report.
Members of Mrs Grants family, including her son, attended the inquest and asked
questions of witnesses. They were understandably concerned about the failure to
provide VTE prophylaxis and the extent to which this contributed to Mrs Grants
demise.
| have not provided you with a full copy of the inquest file because one is held by
your Legal Services Department.
CIRCUMSTANCES OF THE DEATH
As set out above, Marian Grant aged 74 tripped and fell on 14 April. Along with
other family, she was visiting her grandson at university. She was an active lady,
relatively fit, and still working as a care assistant prior to her death. She was
transported by ambulance to the John Radcliffe Hospital. The initial plan was that
she would undergo surgery on the following day, Sunday, but there were other
urgent cases which took priority and therefore the surgery took place first thing on
Monday 16 April. Unfortunately, she died intra-operatively with a medical cause of
death provided by ——_————miieremma of:
ta Pulmonary Embolism
1b Deep Vein Thrombosis
ic Fractured Neck of Femur
CE ors entec that there was a massive pulmonary embolism from
ep vein thrombosis in both legs and that the most likely underlying risk factor for
the DVT was immobilisation following the femoral fracture. He also referred to
histology showing that there were multiple marrow emboli in pulmonary arteries in
addition to fresh thrombo emboli and that the marrow emboli was in keeping with
the recent fracture and likely to have exacerbated the cardio vascular consequence
of thrombo embolism.
CORONER’S CONCERNS
During the course of the Inquest the evidence revealed matters giving rise to
concerns. 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 make this
report to you.
| appreciate there has been an RCA Investigation and an Action Plan. | was
provided with an updated copy of the Action Plan and it is reassuring to note that
several measures have been undertaken to reduce the risk of a similar incident
occurring in future.
| note that the RCA Report states that the Root Cause was ‘Omission to prescribe
chemical or mechanical VTE prophylaxis because of technical difficulties with EPR.
This omission was not resolved at a later date.’ The report goes on to say this
incident is classified as an avoidable VTE event and that this is therefore an
avoidable death by definition and that the failure to provide any prophylaxis meant
that the risk of a fatal PE must have been increased.
| heard evidence about a number of checks and fail-safe procedures. | refer to two
in particular. The first concerned the training, experience and knowledge of nursing
staff on the trauma wards who are very familiar with the requirements for VTE
prophylaxis and a tendency for the nurses to pick up and deal with any omissions
in this regard. The second check is the EPR alerts.
The MATTERS OF CONCERN are as follows:
1. The first concern relates to what are referred to as ‘outlying patients’. Mrs
Grant went from the emergency department to a neuro-science ward
because there were no beds on a trauma ward. It appears that her
placement on a ward other than a trauma ward raised issues in respect of
her care and, in particular, it meant she was not being cared for by trauma
nurses who might ordinarily be expected to pick up the omission concerning
VTE prophylaxis.
| understand it is relatively common for a trauma patient to be placed ona
ward other than a trauma ward. | understand that this may be unavoidable
but | am concerned about there being sufficient safeguards in place. | see
from the Action Plan that recommendations 1 and 7 refer to this issue.
There has been an audit and the trauma co-ordinator is to check VTE
prophylaxis has been prescribed to trauma patients outlying on non-trauma
wards. | seek reassurance that the audit of care for such patients confirms
that the same standard of care is delivered regardless of location. { also
seek information and reassurance about the practical steps taken by the
trauma co-ordinator to check VTE prophylaxis. There were a number of
system checks which failed in this case and it is therefore important that
system checks are effective.
2. The second concern relates to ignoring the VTE prophylaxis alerts on EPR.
| note from the RCA Report that the warning was visible on exiting the
record by all staff. [J explained however that often the warning
would not be seen because sometimes a doctor does not actually exit the
record but keeps it open (albeit secure). It is surprising that from the time
of transfer to the neuro-science ward from ED until the time when the
patient was seen by the Consultant Anaesthetist [J on the
morning of surgery on 16 April that the EPR was accessed 27 times by staff
members and yet none of the staff interviewed recalled seeing the alert. A
system designed with fail-safes in the form of alerts is obviously not
effective if the alerts are not seen or routinely ignored. Recommendation 8
on the Action Plan refers to this issue and i see that an email has been sent
out to the EPR Lead and that a new version of EPR will prevent staff being
able to exit the EPR record until VTE alerts have been dealt with. As
mentioned, it seems though that doctors do not always exit the record and,
as | understand it, the alert will not pop up unless the record is being exited.
It would be appreciated if you could provide some clarification on this and
also address the wider issue of alerts not being acted upon.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you
have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report. | may extend the period on request.
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
| confirm that a copy of this report and your response will be sent to Mrs Grant’s
family.
The Chief Coroner may publish either or both ina 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.
Signed Date ne Sophie Leis
rd". Salter
HM Senior Coroner for Oxfordshire
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