Source · Prevention of Future Deaths

Jonathan Kingsman

Ref: 2021-0238 Date: 13 Jul 2021 Coroner: Simon Milburn Area: Cambridgeshire & Peterborough Responses identified: 1 / 1 View PDF

The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial VTE risk factors and lacking clear completion guidance.

Date 13 Jul 2021

56-day deadline 7 Sep 2021

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths

Coroner's concerns

AI summary

The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial VTE risk factors and lacking clear completion guidance.

View full coroner's concerns

The MATTERS OF CONCERNS are as follows: That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased immobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future; The risk assessment form contains no guidance on its completion and no definition of certain terms.

Responses

1 respondent

Department of Health Social Care Central Government

18 Nov 2021 PDF

Noted

The Department acknowledges the concerns regarding the 2010 Risk Assessment Tool for Venous Thromboembolism (VTE) and refers to NICE guidelines. They note the need for further research to balance VTE risk versus bleeding risk in acute psychiatric settings and that the National Patient Safety Committee will work to identify the best route to take this forward. (AI summary)

View full response

Dear Mr Milburn Thank you for your letter of 13 July 2021 to Sajid Javid about the death of Jonathan Mark Kingsman. I am replying as Minister with responsibility for patient safety and I am grateful for the additional time in which to do so. To begin, I would like to offer my sincere condolences to Mr Kingsman’s family and loved ones. I can appreciate how upsetting the circumstances around his death must be. I have noted carefully your concerns in relation to the Department of Health 2010 Risk Assessment Tool for Venous Thromboembolism (VTE)1. In preparing this response, my officials have made enquiries with NHS England and NHS Improvement (NHSEI), and the National Institute for Health and Care Excellence (NICE). I am advised that NICE guideline 89: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism2, is clear that all acute psychiatric patients should be assessed to identify their risk of VTE and bleeding:
• As soon as possible after admission to hospital or by the time of the first consultant review; and,
• Using a tool published by a national UK body, professional network or peer reviewed journal. NICE does not recommend a particular risk assessment tool, as there is no evidence currently to support the use of one over another. The Guideline explains that a tool commonly used in the NHS for hospital patients is the Department of Health Risk Assessment Tool for Venous Thromboembolism (VTE) (2010) (see Recommendation
1.9.1). 1 Risk assessment for venous thromboembolism (VTE) (nice.org.uk) 2 Overview | Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism | Guidance | NICE

The 2010 Department of Health Risk Assessment Tool acknowledges that the risk factors identified are not exhaustive, and that clinicians may consider additional risks in individual patients and offer thromboprophylaxis (preventative measures against the formation of blood clots) as appropriate.

NICE Guideline 89 notes that the 2010 Department of Health Risk Assessment Tool has not been validated or tested against other tools to evaluate its diagnostic accuracy or effectiveness at correctly identifying people at risk of VTE. The NICE Guideline Committee made a research recommendation in this area, reflecting the uncertainty in the evidence for one risk tool over another but supports its use until tools that incorporate new evidence and have been tested through research can replace it.

You may wish to note that NICE has advised that it will consider the use of specific tools for acute psychiatric patients at its next review of Guideline 89.

I am advised by NHSEI that there is a recognised need for research to be conducted to identify the balance of risk of VTE versus the risk of bleeding with VTE prophylaxis for some groups where NICE requires this (including for acute psychiatry settings) to inform the development of new evidence-based risk assessment tools.

I am informed by the National Institute for Health Research (NIHR) that it has supported or funded a number of research studies in relation to VTE prevention. This includes studies in relation to the cost-effectiveness of VTE risk assessment tools for hospital inpatients and looking at the risk of VTE in patients admitted to acute psychiatric wards. NHSEI advise that once these studies are complete, it will then be feasible to create an updated tool to encompass patients on acute psychiatry wards, where NICE guidelines recommend that VTE prophylaxis (usually through injections of Low Molecular Weight Heparin) should be given if the risk of VTE exceeds the risks of bleeding. The National Patient Safety Committee will work to identify the best route to take this forward.

More generally, VTE prevention continues to be an area of significant focus in relation to patient safety. The ‘Getting it Right First Time’ (GIRFT) Programme has undertaken a national survey in partnership with Thrombosis UK and published a report in September 20213, that makes recommendations for improvement that providers of care can take forward, as well as recommendations to NICE. In addition, the National Patient Safety Committee is currently working to understand, and improve, the contributions that each partner organisation can make in the prevention of healthcare associated VTE.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

MARIA CAULFIELD Minister for Primary Care & Patient Safety

3 TUK-GIRFT-REPORT.pdf (thrombosisuk.org)

Report sections

Investigation and inquest

On 13.03.20 I commenced an Investigation into the death of Jonathan Mark Kingsman, aged 47 years. The Investigation concluded at the end of the Inquest on 12.07.21. The conclusion of the Inquest was that death was as a result of ‘Natural Causes’, The medical cause of death being recorded as: 1a Pulmonary Thromboembolism; 1b Deep Vein Thrombosis;

Circumstances of the death

Mr Kingsman was admitted to Fulbourn Hospital, Cambridge under s2 of the Mental Health Act 1983 on 26.01.21 where he remained until his death on 01.02.20. On admission it was reported that Mr Kingsman had not consumed any fluids for at least several hours. The Doctor on call carried out an initial risk assessment using the Department of Health Template titled ‘Risk Assessment for Venous Thromboembolism(VTE)’ Gateway reference no: 10278. At ‘Step 1’ the document requires an assessment of the patient’s anticipated mobility. Where the patient is ‘NOT expected to have significantly reduced mobility relative to normal state’ the assessor is directed to terminate the assessment. It was agreed evidence at the Inquest that Mr Kingsman fell into this category and likewise agreed that throughout his time in hospital that there were no changes to his mobility which would have prompted a renewed risk assessment. The Inquest also heard evidence that ‘immobility’ was one of a number of potential risk factors for VTE. These included:- obesity; inherited blood clotting disorder; smoking; personal or family history of DVT or PE; dehydration; receipt of certain psychiatric medication(there are others listed on the risk assessment form itself). At least some of these potential risk factors may have been present in this case although on the evidence presented it was not possible to conclude to the required standard which, if any, may have played a part in Mr Kingsman’s death. None of these risk factors was considered as part of the risk assessment process as Mr Kingsman did not get past ‘Step 1’ referred to above. Additional risk factors including those identified above are only considered at ‘Step 2’ in the risk assessment process. The evidence was that at no stage during his hospital admission was Mr Kingsman ‘expected to have significantly reduced mobility relative to normal state’ and therefore there was no stage at which these risk factors were prompted for consideration at ‘Step 2’ in the risk assessment process. Despite this Mr Kingsman died as a direct result of a pulmonary thromboembolism caused by deep vein thrombosis. The Inquest was also advised that the risk assessment form contains no guidance on its completion and no definitions of some of the terms used eg ‘significantly reduced mobility compared to normal state’;

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Report details

Reference: 2021-0238
Date of report: 13 July 2021
Coroner: Simon Milburn
Coroner area: Cambridgeshire & Peterborough

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Sep 2021.

Sent to

Department of Health and Social Care

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Data: judiciary.uk under OGL.