Source · Prevention of Future Deaths

David Lewsey

Ref: 2023-0463 Date: 22 Nov 2023 Coroner: Andrew Cox Area: Cornwall and the Isles of Scilly Responses identified: 2 / 2 View PDF

Critical pain information was not accurately relayed from reception staff to clinical practitioners, and a need for improved staff training on recognizing and escalating high-risk pain symptoms was identified.

Date 22 Nov 2023

56-day deadline 17 Jan 2024 est.

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Evidence was heard at inquest that if the concern of a terrible pain in his side, reported in Mr Lewsy’s first telephone call to reception staff, had been passed on to the ANP, the initial discussion between Mr Lewsey and the ANP may have started down a different path. It was recognised that the doctors and nurses dealing with duty calls work under pressure, and it was felt that ensuring accurate and complete information was passed to them may reduce that pressure and facilitate the provision of a better service to patients.
- The inquest also heard that reception staff had some training to raise a red flag if pain in the ‘chest’ was reported to them. Mr Lewsey said he had pain in his ‘side’ but the precise location of that pain was not explored further. While it was said in evidence that, typically, a PE will present with pleuritic or chest pain, it was noted that NICE guidance includes abdomen pain. You may wish to reflect on whether additional training is required for all staff on how to manage complaints of pain in the chest or abdomen particularly in patients who have recently undergone procedures that may have left them relatively immobile and at an increased risk of developing a DVT.

Responses

2 respondents

Old Bridge Surgery

14 Dec 2023 PDF

Action Taken

The practice reviewed the call recording and held a training afternoon on telephone triage and call handling. They highlighted the process of flagging calls for concern and discussed presentations of pulmonary emboli, and intend to audit details recorded by reception staff. (AI summary)

View full response

Dear Mr Cox

Thank you for your letter of 22nd November 2023 and the regulation 28 report. I note that you have highlighted some areas of concern. I reviewed the call recording of the initial call to reception. The whole Practice team then attended a training afternoon on Wednesday 6th December. As a major part of the training afternoon, we held a session on telephone triage and call handling. During the session we specifically highlighted the process of flagging calls for concern at the stage that the reception team are adding them to the duty call list. We discussed the types of calls that may cause concern and the importance of providing as much detail as possible in the free text “reason for the call” area. The entire team of clinicians who may be involved in triaging calls from the duty call list discussed and reflected upon the presentation of pulmonary emboli, including the rare occurrence of abdominal rather than chest pain. We also discussed other presentations of emergency medical and surgical problems in patients who have recently had a stay in hospital. Our intention would be to audit in future the fullness of details recorded by reception staff for calls added to the duty list and will present the results at a future training session within the next six months.

Information Classification: CONTROLLED I would be grateful if you could let me know if the actions taken (and proposed) fulfil the requirements of the regulation 28 notice?

National Institute for Health and Care Excellence Other

6 Feb 2024 PDF

Noted

NICE acknowledges the concerns, explains the guideline development process for venous thromboembolism prophylaxis, and notes that guidelines are not mandatory and are reviewed periodically. (AI summary)

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Dear Mr Cox,

I write in response to your regulation 28 report regarding the very sad death of David John Lewsey. I would like to express my sincerest condolences to his family.

We have considered the circumstances surrounding Mr Lewsey’s death and I have addressed below the matter of concern directed to NICE.

In developing our guideline on venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism [NG89], the committee considered a number of pharmacological and mechanical prophylaxis options, including foot impulse devices or foot pumps (FID) and intermittent pneumatic compression devices (IPCD). The committee considered these interventions on their own and in different combinations.

The trial data for all mechanical prophylaxis options showed they were used for longer durations than in current clinical practice, where early mobilisation is encouraged, and so the committee felt that it may not be possible to replicate the efficacy levels reported.

Furthermore, as it was not possible to include any side effects for mechanical prophylaxis options in the analysis the committee determined that their cost-effectiveness might be over- estimated.

More generally, the committee noted there was uncertainty around the relative effectiveness estimates for different prophylaxis strategies and so the committee opted to give a choice of prophylaxis options, noting that some people may have contraindications.

The committee’s consideration of the evidence underlying recommendations for thromboprophylaxis in elective knee replacement surgery are presented in chapter 27 of volume 2 of the full guideline.

When exercising their judgment, professionals and practitioners are expected to take NICE guidelines fully into account, alongside the individual needs, preferences and values of their

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patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian, or preclude other treatment options from being offered.

Your report has been shared with our guideline surveillance team for further consideration when the guideline is reviewed.

I hope that you find this information helpful.

Report sections

Investigation and inquest

On 21/11/23, I concluded an inquest into the death of David John Lewsey who died on 15/12/22 at the age of 68. . The medical cause of death was recorded as: 1a) Pulmonary thromboembolism 1b) Deep vein thrombosis of left calf 1c) Knee replacement operation

I recorded a Narrative Conclusion that Mr Lewsey died from a known complication of an elective surgical procedure.

Circumstances of the death

Mr Lewsey was a 68-year-old man who underwent a left knee replacement on 29/11/22. Upon discharge, he was prescribed with two weeks of aspirin to reduce the risk of developing a clot and codeine for pain relief. The codeine caused Mr Lewsey to become constipated.

On 15/12/22, he rang the surgery for treatment to relieve his constipation. In the first call with reception staff, he reported a ‘terrible, terrible pain in his side.’ This information was not passed on to the Advanced Nurse Practitioner (ANP) who returned Mr Lewsey’s call.

In his first call with the ANP, Mr Lewsey said that his left side hurt like he had a stitch and that he felt pain when he breathed in. I found as fact that it was more likely than not that this was caused by a developing pulmonary embolus.

No consideration was given to excluding a PE as a possible cause of the Information Classification: CONTROLLED pain. It is more likely than not that the PE was caused by a DVT in his leg that developed following Mr Lewsey’s immobility after his knee operation. Mr Lewsey collapsed later that evening at his home address and could not be resuscitated.

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Report details

Reference: 2023-0463
Date of report: 22 November 2023
Coroner: Andrew Cox
Coroner area: Cornwall and the Isles of Scilly

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Jan 2024 (estimated).

Sent to

National Institute for Health and Care Excellence

Old Bridge Surgery

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Data: judiciary.uk under OGL.