Source · Prevention of Future Deaths

Ann Smith

Ref: 2020-0223 Date: 5 Nov 2020 Coroner: Caroline Beasley-Murray Area: Essex Responses identified: 2 / 1 View PDF

There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also receiving treatment-dose Clexane.

Date 5 Nov 2020

56-day deadline 15 Feb 2021 est.

Responses identified 2 of 1

Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths

Coroner's concerns

AI summary

There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also receiving treatment-dose Clexane.

View full coroner's concerns

1. There was uncertainty as to how to deal with the anti-coagulation aspect of the deceased’s care in the wake of the fall. There is the lack of a local protocol (part of the Falls Policy) for the management of the sub-group of patients over 65 on anticoagulants and being given treatment dose of clexane for another clinical reason eg suspected pulmonary embolus, who sustain head trauma.

Responses

2 respondents

The Princess Alexandra Hospital NHS Trust NHS / Health Body

30 Dec 2020 PDF

Action Planned

The Trust has established a multi-disciplinary Anticoagulation/Falls Tasking Group to develop an Action Plan addressing the management of anticoagulation in patients over 65 who sustain a head trauma; an update is promised by the end of March 2021. (AI summary)

View full response

Dear Coroner Beasley-Murray, I write in the matter of the late Ann Smith in response to your recent Regulation 28 Report to prevent future deaths. Ms Smith was admitted to Princess Alexandra Hospital on 8th September 2019. On 9th September she suffered an unwitnessed fall which resulted in a head injury. She sadly died on 13th September 2019 and your inquest into her death was held on 3rd November 2020. You were concerned that ‘there was uncertainty in how to deal with the anti-coagulation aspect of Ms Smith’s care in the wake of her fall. That there was a lack of a local protocol for the management of the sub-group of patients over 65, on anticoagulants, and being given a treatment dose of clexane for another clinical reason, eg suspected pulmonary embolus, who then sustain a head trauma’. The speed at which action is taken following a fall is clearly significant, as is the importance of the patient having a clearly identified anticoagulation action plan post fall. To that end, the Trust has established a multi-disciplinary Anticoagulation/Falls Tasking Group comprising of the Associate Medical Director for the Medicine Healthcare group, the Anticoagulation Pharmacist and the Lead Nurse for Falls Prevention. This group has developed an Action Plan, a copy of which I share with you. Whilst the actions from this plan are still ongoing, I am confident that the Trust is on course to deliver the necessary changes to ensure that there are no further severe harms or deaths from this type of incident. I propose to update you again by the end of March 2021.

The Princess Alexandra Hospital NHS Trust NHS / Health Body

26 Aug 2021 PDF

Action Taken

The Trust has completed updates to the Falls Prevention policy, quick reference guides, and Nerve Centre software; mandatory questions have been added to the Datix incident management system, and the action has been formally added to the Trust's Strategic Quality Improvement Programme and Corporate Risk Register. (AI summary)

View full response

Dear Coroner Brookes,

Re: Ann Margaret Smith (Deceased)

I am writing to you in my role of Medical Director at The Princess Alexandra Hospital NHS Trust (PAHT) regarding the inquest into the death of Mrs Ann Smith. This inquest was heard before Senior Coroner Beasley-Murray on 3rd November 2020. In conjunction with her conclusion, Ms Beasley-Murray issued a Regulation 28 report to which PAHT responded on 30th December 2020. Part of that response promised a subsequent update would be provided to the Senior Coroner by March 2021. I have now established that this update was unfortunately not forthcoming, primarily as a result of the overwhelming priorities of the Covid wave. Please accept my sincere apologies for this oversight. Ms Smith was admitted to Princess Alexandra Hospital on 8th September 2019. The following day she suffered an unwitnessed fall which resulted in a head injury and she sadly died on 13th September 2019. Senior Coroner Beasley-Murray indicated in her Regulation 28 report that she was concerned that ‘there was uncertainty in how to deal with the anti-coagulation aspect of Ms Smith’s care in the wake of her fall. That there was a lack of a local protocol for the management of the sub-group of patients over 65, on anticoagulants, and being given a treatment dose of clexane for another clinical reason, eg suspected pulmonary embolus, who then sustain a head trauma’. The importance of the patient having a clearly identified anticoagulation action plan post fall remains a priority for PAHT. The Action Plan developed by our multi-disciplinary Anticoagulation/Falls Tasking Group continues apace and I include with this letter the previously promised update of progress with that. PAHT remains committed to ensuring that all of our clinical, nursing and allied health professional staff are fully conversant in falls prevention and falls management. Our Strategic Falls Prevention Plan for 2021/22 is focussed on continued training and oversight to ensure preventative actions.

We continue to make progress with regards to overall patient falls with harm, and I am pleased to say that we have achieved a 10% reduction during quarter 4 of 2019-20, and also in each of quarters 1 & 2 of 2021. Our goal is to reduce the number by 50% by the end of March 2022. I remain confident that the Trust is on course to deliver the necessary changes required.

Report sections

Investigation and inquest

On 13 September 2019 I commenced an investigation into the death of Ann Margaret Smith. The investigation concluded at the end of the inquest on 3 November 2020. The conclusion of the inquest was that she died as a result of an accident contributed to by natural disease. The cause of death was 1a) subdural and intracerebral haemorrhage
11) Hypertensive Heart Disease and Bronchopneumonia

Circumstances of the death

The deceased was admitted to Princess Alexandra Hospital on 8 September 2019 and on 9 September she suffered an unwitnessed fall. She sustained a head injury and she died on 13 September 2019

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2020-0223
Date of report: 5 November 2020
Coroner: Caroline Beasley-Murray
Coroner area: Essex

Responses identified

Responses identified 2 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Feb 2021 (estimated).

Sent to

Princess Alexandra Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.