Source · Prevention of Future Deaths

Neil Hickman

Ref: 2022-0064 Date: 28 Feb 2022 Coroner: Mary Hassell Area: Inner North London Responses identified: 1 / 2 View PDF

Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due to a lack of funding for chelation therapy.

Date 28 Feb 2022
56-day deadline 25 Apr 2022 est.
Responses identified 1 of 2
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due to a lack of funding for chelation therapy.
View full coroner's concerns
Mr Hickman was given frequent platelet transfusions at K&C, but his ferritin levels were not measured. When he was referred to UCLH, his ferritin level was found to be hugely raised. He was then treated with chelation therapy and ultimately his ferritin returned to a safe level, so this did not impact upon the outcome. However, it might for another patient.

I think the reason that K&C does not measure the ferritin levels in such a situation is because K&C does not have funding for chelation therapy to treat iron overload. However, if iron overload is detected, then a referral centre such as UCLH can be called for advice, and the patient and their family can be informed so that they have the option of seeking private treatment.

Responses

1 respondent
Kent and Canterbury Hospital NHS / Health Body
28 Feb 2022 PDF
Action Taken

The hospital has implemented a policy that all Myelodysplastic Syndrome patients undergoing frequent red cell transfusions and being referred for a bone marrow transplant will have their ferritin levels measured. (AI summary)

View full response
Dear Madam

Mr Neil Hickman – PFD Response

Thank you for your Prevention of Future Death (PFD) Report dated 28 February 2022 sent pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 concerning the death of Mr Neil Hickman on 21 August 2021.

I understand that during the course of the inquest you heard evidence that revealed matters giving a rise to a concern that needs to be addressed to prevent a future death. Specifically, you are concerned that when Mr Hickman was referred for a bone marrow transplant, his ferritin levels were not checked despite him undergoing frequent blood transfusions.

Your PFD Report was discussed in the Haematology Departmental business meeting on 10 March
2022. It has now been agreed that all Myelodysplastic Syndrome patients that are undergoing frequent red cell transfusions and being referred for a bone marrow transplant will have their ferritin levels measured. This will ensure that if iron overload is detected, appropriate measures can be initiated including referral to a specialist centre for urgent treatment. This action has been implemented with immediate effect.

Lastly, I would like to thank you for bringing your concern to our attention and can assure you and Mr Hickman’s family that the Trust will continue to improve on the high standards we set ourselves in East Kent Hospitals.

Report sections

Investigation and inquest
On 25 August 2021, one of my assistant coroners, Sarah Bourke, commenced an investigation into the death of Neil Hickman aged 63 years. The investigation concluded at the end of the inquest earlier today. I made a determination at inquest of death by natural causes.
Circumstances of the death
Neil Hickman was treated at Kent and Canterbury Hospital (K&C) for myelodysplastic syndrome and then was referred to University College London Hospital (UCLH) for stem cell transplant. However, he died before the transplant could take place. His medical cause of death was: 1a disseminated angio-invasive mycotic infection 1b immunosuppression 1c myelodysplasia
Copies sent to
University College London Hospitals NHS Trust

Similar PFD reports

Shared signals

Related inquiry recommendations

Similar themes

Report details

Reference
2022-0064
Date of report
28 February 2022
Coroner
Mary Hassell
Coroner area
Inner North London

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 Apr 2022 (estimated).

Sent to

East Kent Hospitals University NHS Foundation Trust
Kent and Canterbury Hospital

Source links