Source · Prevention of Future Deaths

Captain James Bedforth

Ref: 2016-0368 Date: 18 Oct 2016 Coroner: Christopher Dorries Area: South Yorkshire (West) Responses identified: 1 / 2 View PDF

Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation management, and poor note-keeping further compromised care.

Date 18 Oct 2016

56-day deadline 4 Jan 2017

Responses identified 1 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation management, and poor note-keeping further compromised care.

View full coroner's concerns

1. The inquest heard that the scanning practice followed after the first attendance was in accordance with NICE guidelines (indeed possibly a little in excess of the guidance) which did not include scanning of the lower leg. This was said to be on the basis that not all lower leg DVTs will be visible. Yet it became apparent that that there is mixed practice on this point, some hospitals clearly consider that lower leg scanning is worthwhile. Hindsight strongly suggested that Captain Bedforth was developing clots in the left lower leg at the time of the first visit. The inquest found that a full leg scan might have provided the hospital with an opportunity to treat Captain Bedforth although it was accepted that no-one could be certain of this. Whilst a separate Regulation 28 report is being sent to the Secretary of State for Health seeking further consideration of the NICE guidelines on lower leg scanning, the Trust may wish to consider their own practice on this point in the meantime. The Trust may also wish to consider whether discharge after a negative scan may be more closely supervised by a doctor in certain circumstances
2. The evidence of 'safety-netting' after the first attendance (and/or subsequent attendance for scans) was poor and of considerable concern. As made clear in my written findings this was possibly of relevant as to Captain Bedforth's subsequent decision on seeking medical attention in or upon return from China.
3. Whilst it is accepted that Emergency Departments are often busy, and sometimes exceptionally so, there was criticism at the inquest of the priority given to Captain Bedforth on his second admission when he was displaying classical symptoms of a DVT/PE. It appears that he was not medically assessed for at least two and a half hours after admission by ambulance. Dalteparin was not prescribed until three hours post-admission and there was no evidence as to exactly when it was given (although likely shortly thereafter).
4. An expert witness (an ED physician) was critical of the placement in AMU and clerking in by a medical student although it is not suggested this of itself made a difference as to survival.
5. There was no criticism of the use of 50mg Alteplase but there was a lack of clarity as to whether this was followed by an infusion. A further expert witness (a haematologist) criticised the subsequent use of unfractionated Heparin and a test of Heparin level seems to have taken a long time from sampling to delivery to the laboratory and later result. The evidence was strongly suggestive of over-anticoagulation by Heparin.
6. A number of issues were raised as to note-keeping or clarity of note-keeping, most particularly as regards delivery of medications.

Responses

1 respondent

Department of Health Central Government

22 Feb 2017 PDF

Noted

The Department of Health acknowledges the coroner's concerns regarding lower leg scanning for DVT, but refers the matter to NICE and the Royal Society of Medicine Venous Forum for further comment. (AI summary)

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Philip Dunne MP Minister of State for Health Department of Health Richmond House Our ref: 1055768 79 Whitehall London Your ref: SWIA 2NS Tel: 020 7210 4850 Mr Christopher Dorries HM Senior Coroner South Yorkshire (West) The Medico-Legal Centre Watery Street Sheffield S3 7ET 22 February 2017 Dc Mr Dxvn Thank you for your letter of 18 October 2016 following the inquest into the death of Captain James Michael Bedforth. I am responding as the Minister with responsibility for hospital care at the Department of Health. I was sorry to hear of Captain Bedforth 's death: Please extend my condolences to his family and loved ones: Your report explained that Captain Bedforth attended hospital in Barnsley on 18 April 2015 with pains in his left around the knee. Appropriate investigations were made (in accordance with NICE guidelines) which included scanning of the upper but not lower Nothing was found and the patient was discharged. On 29 June 2015 Captain Bedforth collapsed at his home following a flight: He was admitted to hospital with symptoms of_ Vein Thrombosis (DVT) where his condition worsened. Following a CT scan Captain Bedforth was treated with Heparin, but his condition deteriorated markedly after a seizure late that evening: A further CT scan showed an unsurvivable left sided acute cerebral haemorrhage: The inquest found strong inference that this had arisen from over-anticoagulation with Heparin. Captain Bedforth died the following morning; 30 June 2015. You asked that the Department of Health considers whether it is appropriate for further research to be conducted as to the question of lower leg scanning: leg leg: long Deep

The inquest heard that the scanning practice followed after Captain Bedforth's first attendance in April 2015, was in accordance with NICE guidelines which do not include scanning the lower As it became apparent there is mixed clinical practice on this point, your view is that some hospitals consider that lower leg scanning is worthwhile. As most hospitals are, or should be, working to NICE guidelines, I therefore advised that you should consider inviting NICE to respond to this case directly. officials provided you with contact details and I understand that NICE are looking into this and will respond directly to you and copy me into their reply. I have also consulted the Royal Society of Medicine Venous Forum (RSMVFF and asked for their comments on this case. RSMVY advises that it is not possible, without full clinical details on Captain Bedforth'$ case, for them to comment on the specifics or ascertain whether the detailed recommendations of NICE clinical guidelines (CG144) were followed. However; RSMVF also out that the evidence for treating distal DVT alone is weak and cites a recent CACTUS trial (lancet haematology 2016) which showed no benefit in treating symptomatic below knee DVT: RSMVF is of the opinion that that even if Captain Bedforth had had a full scan; and had been found to have a below knee DVT in April 2015,the evidence is not clear on whether he should have been immediately anticoagulated at that time. As such RSMVF also recommend that these issues be referred t0 NICE for comment as the type of scanning used for these investigations originated with the NICE guideline (CG144). [ hope this reply is helpful and I am grateful to you for bringing the circumstances of Captain Bedforth's death to my attention: Tam copying this letter to Sir Andrew Dillon, Chief Executive of NICE Auel L PHILIP DUNNE leg: My" points leg

Report sections

Circumstances of the death

Captain Bedforth was a senior long haul airline pilot. Such an occupation obviously involves prolonged seated immobility although there is some opportunity for movement. On the 18th April 2015 he attended the hospital at Barnsley with pains in his left leg around the knee. Appropriate investigations were made (in accordance with NICE guidelines) which included scanning of the upper but not lower leg. Nothing was found and Captain Bedforth was discharged. On 29th June 2015 Captain Bedforth collapsed at his home some hours after a flight from China. He was admitted to the hospital with classical symptoms of a DVT and much was said at the inquest about the promptness or otherwise of initial examination and diagnosis. The Trust were represented at the inquest and a full reasoned conclusion was subsequently given so those matters are not covered in detail here but will be mentioned in section 5 of this report below. The captain further collapsed at approximately 1445 and was treated with Alteplase. A CT scan showed pulmonary embolus and an early left sided cerebral infarction due to a paradoxical embolism. Heparin treatment was subsequently given (and stopped at 2235). The Captain deteriorated markedly after a seizure at 2345,. A further CT showed an unsurvivable left sided acute cerebral haemorrhage. The inquest found a strong inference that this had arisen from over-anticoagulation with Heparin (again see section 5 below). Death occurred at 1145 the following morning 30th June 2015.

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Report details

Reference: 2016-0368
Date of report: 18 October 2016
Coroner: Christopher Dorries
Coroner area: South Yorkshire (West)

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: 4 Jan 2017.

Sent to

Barnsley Hospital NHS Trust

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.