Source · Prevention of Future Deaths

Margaret Hions

Ref: 2016-0047 Date: 12 Feb 2016 Coroner: Jonathan Layton Area: Carmarthenshire and Pembrokeshire Responses identified: 1 / 1 View PDF

Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.

Date 12 Feb 2016

56-day deadline 8 Apr 2016 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.

View full coroner's concerns

The MATTERS OF CONCERN is as follows:

(1) That there should be a review of the current Health Board practice in the prescribing of tinzaparin medication and the monitoring of blood levels.

(2) That the importance of monitoring creatinine clearance as per Health Board clinical pharmacy policy to be reiterated to medical team and pharmacists. These matters were identified by a Root Cause Analysis Investigation report but it was unclear at the inquest whether these recommendations have yet been acted upon. 2

Responses

1 respondent

Margaret Hions

29 Mar 2016 PDF

Action Planned

The Health Board has reviewed its practice in the prescribing of tinzaparin and monitoring of blood levels, and a revised guideline has been produced, subject to consultation and approval; the importance of monitoring creatinine clearance is being reiterated to clinicians and pharmacists. (AI summary)

View full response

Dear Mr Layton Inquest touching the death of Mrs Margaret Hions Thank you for you correspondence, enclosing the Regulation 28 report; following the inquest of Mrs Hions_ I apologise for the shortcomings in her care that were identified as part of the inquest and investigation into Mrs Hions death namely the prescribing of Tinzaparin and the monitoring of creatinine in accordance with Health Board policy In relation to recommendation to review Health Board practice in the prescribing of tinzaparin medication and monitoring of blood levels, I can confirm that this has been reviewed and a revised guideline for prescribing and monitoring low molecular weight heparin had been produced_ This is currently subject to consultation within the Health Board and will be presented to the next scheduled meetings of both the Medicines Management Group and Clinical Policy Review Group for approval: importance of monitoring creatinine clearance is being reiterated by letter from the Medical Director to all clinicians and clinical pharmacists; this will also be included in the Medicines Management Group newsletter which is widely circulated and by global e-mail to all staff, upon approval of the above guideline. Swyddteydd Corforaethol, Adeilad Ystwyth, Corporate Offices Ystwylh Buildirig Cadeirycd Cnair Hafan Derwven, Parc Dewi Sant; Hecl Ffynnon Jod. Hafan Derwen, St Davids Park, Job'$ Well Road , Mrs Bernardine Rees OBE Caerfyrcdin, Sir Gaorfyrddir, S431 3BB Camarthen_ Carmarlnershire; S431 3BB Prif WelthredwiIChief Executive Mr Steve Moore the The

If you require further information, please do not hesitate to contact me or Louise OConnor, Assistant Director (Patient Experience) on the above contact numberle-mail:

Report sections

Investigation and inquest

On 3rd September 2013 I commenced an investigation into the death of Margaret Hions . The investigation concluded at the end of the inquest on 12th February 2016. The conclusion of the inquest was a narrative conclusion namely that: Margaret Hions died on 27th August 2013 from pulmonary infarction and coronary artery atherosclerosis in an elderly woman who had sustained breakdown of a left gluteal haematoma caused by tinzaparin therapy. There were shortcomings in the management of her care at Glangwili Hospital.

Circumstances of the death

(1) Mrs Hions was admitted to Glangwili Hospital on 1 July 2013 with increasing shortness of breath, decreased mobility, loss of appetite, nausea and vomiting. At the time of her admission she was prescribed warfarin. A decision was made to replace warfarin with tinzaparin. (2) Mrs Hions remained in hospital and during her admission a large bruise was observed which expanded rapidly. (3) As a result of this the tinzaparin was stopped. (4) Mrs Hions was subsequently transferred to the Prince Philip Hospital where she passed away on 27th August 2013.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2016-0047
Date of report: 12 February 2016
Coroner: Jonathan Layton
Coroner area: Carmarthenshire and Pembrokeshire

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: 8 Apr 2016 (estimated).

Sent to

West Wales General Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.