Date of report: 15/05/2023
Deceased name: Julie Hancock
Coroner name: Andrew Cox
Coroner Area: Cornwall and the Isles of Scilly
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Royal Cornwall Hospital
|REGULATION 28 REPORT TO PREVENT FUTURE DEATHS|
|THIS REPORT IS BEING SENT TO: |
1. [REDACTED], Medical Director, Royal Cornwall Hospital, Truro
I am Andrew Cox, HM Senior Coroner for the coroner area of Cornwall & Isles of Scilly.
|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.
In March 2022, I commenced an investigation into the death of Julie Louise Hancock, aged 53, who died on 28/3/22. The investigation has not yet concluded and the inquest was adjourned today after the matters I am writing to you about came to light.
|4||CIRCUMSTANCES OF THE DEATH |
Julie had a past medical history that included rheumatoid arthritis and hypertension. In December 2021, she was offered staged bilateral knee replacements. She was assessed by [REDACTED] as being at high risk of developing a DVT. She had a nurse-led pre-op assessment on 26/1/22 when, I am told, a further risk assessment was not done, in accordance with policy at the time.
On 2/3/22, she had a right total knee replacement. She was discharged on 5/3/22 and died at home on 28/3/22.
At post-mortem, her cause of death was found to be:
1a) Pulmonary embolus
1b) Deep vein thrombosis
II) Immobility following right knee replacement
|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 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. – I enclose the bundle of evidence.
At pp A32-A54, you will find what I am told is the Trust’s Guideline Summary for Thrombosis Prevention and Anticoagulation. At p42, following elective knee replacement, it is suggested clinicians may choose any one of
Aspirin [REDACTED] for 14 days
LMWH for 14 days and anti-embolism stockings
Rivaroxaban [REDACTED] once daily for 14 days
As matters of fact, I am told Mrs Hancock was prescribed 14 days of aspirin and, in apparent error, one unidentified doctor also prescribed Dalteparin which was stopped after a single dose. It is of concern that the doctor cannot be identified and I have no record of the decision-making.
At C32, you will find the Trust’s full guidance for drug prophylaxis following elective knee replacement which is taken from its Thrombosis Prevention and Anticoagulation Policy v9.0 dated Feb 2022. It provides:
Low risk – Aspirin [REDACTED] daily for 14 days
High Risk – Rivaroxaban [REDACTED] daily for 14 days or
Dalteparin or Enoxaparin for 28 days plus stockings (until discharge.)
[REDACTED] had not seen the full guidance previously despite it having been published for over a year which, as a consultant orthopaedic surgeon, is of concern in itself.
[REDACTED] further said that Mrs Hancock was high risk yet she appears to have been given prophylaxis for a low risk patient because the summary guidelines appear not to reflect accurately the full guidance.
[REDACTED], as I understood [REDACTED], said that it had been [REDACTED] practice to prescribe aspirin to all high-risk patients since (at least) February 2022. This raises the question of whether other patients have died from a PE or DVT because of wrongly prescribed prophylaxis that have not been reported to this Office. You will need to consider the position.
I have only considered the situation as it came before me, namely, for an elective knee replacement. As I understand the anticoagulation policy will have a much wider reach than that there is an obvious need to consider the implications across all the Trust’s services.
|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.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 13/7/23. 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:
– Family of Mrs Hancock;
– [REDACTED] (GP)
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.