Source · Prevention of Future Deaths

Michael Hopkins

Ref: 2018-0331 Date: 1 Oct 2018 Coroner: Martin Fleming Area: West Yorkshire (West) Responses identified: 1 / 1 View PDF

Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent surgery after sustaining trauma.

Date 1 Oct 2018
56-day deadline 26 Apr 2019 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent surgery after sustaining trauma.
View full coroner's concerns
The MATTER OF CONCERN is as follows: To review current practice guidelines with respect to the information provided to patients on discharge from hospital that may be at risk of the formation of thromboembolisms given have had recent surgery after sustaining a trauma ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that Bradford Teaching Hospitals NHS Foundation Trust are in a position to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 of its date; [ may extend that on request: Your response must contain details of action taken Or proposed to be taken, setting out the timetable for such action Otherwise you must explain why no action is proposed: RT3589 pain pain _ day they . days . Period -

Responses

1 respondent
Bradford Teaching Hospital NHS Trust NHS / Health Body
2 Oct 2018 PDF
Action Planned

The Trust has developed a revised patient leaflet regarding blood clot risk assessment, to be introduced on 1st December 2018. The Quality Committee will review the leaflet's use and impact. (AI summary)

View full response
Dear am writing in response to your letter of 2nd October 2018, in relation to inquest, which touched the death of Michael Christopher Hopkins In your letter; you requested a response in relation to the 'Regulation Report-Action t0 Prevent Future Deaths'_ The Foundation Trust has been working hard to ensure that all eligible patients receive an assessment of their risk of developing blood clots, and can demonstrate consistent compliance with the relevant perfomance indicators. Since the Regulation Report was received, we have reviewed infomation provided to all patients (not just those who have experienced a trauma); following that assessment of risk and as a result, the Trust has developed a revised leaflet that all patients will receive. have attached an example of the Teaflet to thls letter, and confirm this leaflet wll be introduced from the 1" December 2018. Our Quality Committee has asked for further assurance at a future meeting in relation to the consistency with which the leailet is used (for instance the verbal advice whlch is given) , and also Its impact on the patients who receive it. Weare; as a Foundation Trust; committed to leaming from incidents where there were modifiable or preventable factors, and believe that the summary of our response demonstrates this commitment:.

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Report details

Reference
2018-0331
Date of report
1 October 2018
Coroner
Martin Fleming
Coroner area
West Yorkshire (West)

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: 26 Apr 2019 (estimated).

Sent to

Bradford Teaching Hospitals NHS Trust

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