Peter Unsworth

Dear Ms Topping,

Re: Regulation 28 Report to Prevent Future Deaths – Peter James Michael Unsworth, date of death 29th July 2018.

Thank you for your Prevention of Future Deaths Report issued under Regulation 28 of the Coroners’ (Investigations) Act 2013 (the “report”) dated 1 December 2020 concerning the death of Peter James Michael Unsworth on 29th July 2018. Firstly, I would like to express my deep condolences to Mr Unsworth’s family.

The regulation 28 report concludes Mr Unsworth’s death was a result of 1a Pulmonary Thrombo-Embolism and 1b Deep Vein Thrombosis.

Following the inquest, you raised concerns in your report to NHS England and NHS Improvement regarding:

1. The advice provided by the Consultant Haematologist related to a very complex medical situation. It was not recorded in writing. The Consultant Orthopaedic surgeon did not record it in the patient’s records nor email his understanding of the advice to the Consultant Haematologist for confirmation of what he understood the advice to be.
2. The Consultant Haematologist did not confirm her advice in writing or make any record of the advice given.
3. As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the advice.

The Trust carried out an internal investigation and recommended adopting a ‘read back’ approach to the provision of verbal clinical advice or information to check understanding of any advice. The Trust takes the Situation, Background, Assessment, Recommendation (SBAR) approach to communication which is a structured framework for communication that enables information to be transferred accurately between individuals. In addition, Human Factors training events are held NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH

16th March 2021

regularly as part of the postgraduate education programme. These events focus on improving documentation and communication between team members.

For your second concern, the Trust has reiterated to all staff and clinicians the need to document verbal advice or information contemporaneously within the patient’s notes in line with GMC Good Medical Practice 19, 21 and continues to audit medical records to monitor this and other aspects of record keeping to reinforce good practice. As an organisation, the documentation of specialist advice had been embedded in the curriculum for Junior Doctors and is emphasised at regular Trust events.

Going forward the documenting of specialist advice will be further strengthened by the introduction of Electronic Patient Records which will allow clinicians to input information into health records in real time. It is anticipated that this system will go live within the Trust in December 2021.

Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information.

Dear ,

I am writing to confirm the action that the General Medical Council has taken in response to HM Assistant Coroner Caroline Topping’s Regulation 28 report into the death of Mr Peter James Michael Unsworth.

Upon receipt of the report the GMC’s Triage team has worked with our local Employer Liaison Service to obtain further information in relation to the incident and doctor’s involved. This resulted in obtaining the local investigation report into the incident from Ashford and St Peter’s Hospital.

We have now reviewed the local report and have taken the following actions in relation to the two doctors involved:

1. Dr
– GMC Reference

We note that Dr requested specialist advice from a Consultant Haematologist which was provided over the telephone. As a result of Dr interpretation of the advice provided to him he reduced the patient’s dose of clexane. The conversation with the Haematologist was not added to the clinical notes and a letter confirming the decision to reduce the dose was not sent for a month after the conversation happened.

Sadly after this reduction the patient went on to suffer pulmonary emboli which occluded his pulmonary arteries causing him to pass away on 29 July 2018.

After review the GMC’s Triage team have decided that further enquiries are required into the allegations against Dr . As a result a provisional enquiry has now been opened which will allow the GMC to obtain copies of Mr Unsworth’s clinical records and an independent clinical opinion. The clinical opinion will address whether there are any fitness to practise concerns about the actions of Dr .

We will attempt to complete our initial review into the actions of Dr in around three months. This may be impacted by the current pandemic but where possible we are progressing our investigations whilst at the same time being mindful of the local environment and challenges.

2. Dr
– GMC Reference

In addition to the actions of Dr the GMC’s Triage team has also review Dr involvement in the care provided. Our decision maker has decided that no further action or investigation should be carried out into Dr actions.

In making their decision they made the following comments:

“We have carefully considered all of the information you provided within your Regulation 28 notification. We have also sought further information from the Responsible Officer (RO) at St Peter’s Hospital.

We have reviewed a copy of the hospital’s Significant Incident report which explains that it is unlikely that Dr would have advised that a reduction in dose was appropriate, as it would not be her normal practice in this scenario as it would be contrary to established management principles.

Furthermore, the information we received indicated that it would normally be for the recipient of the advice to record it in the medical notes, and where a doctor is giving advice over the phone, the person giving the advice would not always be expected to record it.

Taking this information into consider, it appears that the responsibility of ensuring a written record was made, did not lie with Dr . We can see that there has been a full SI investigation which has addressed these issues, as such we don’t consider any further action is required by the GMC regarding Dr .”

I hope that this email has confirmed the actions and decisions taken in relation to the Regulation 28 report. If you would like to discuss this matter please do not hesitate to contact me on my direct telephone number.

Kind Regards,

Investigation Manager

3 Hardman Street Manchester M3 3AW

Web: www.gmc-uk.org