Source · Prevention of Future Deaths

Nicola Tweedy

Ref: 2015-0095 Date: 12 Mar 2015 Coroner: Jacqueline Lake Area: Norfolk Responses identified: 2 / 1 View PDF

Critical safety procedures were missed, including failure to provide specific aftercare information and incomplete Thromboprophylaxis Risk Assessments, which should have flagged patient risk factors earlier. Discharge notes were also incomplete and checklists unfulfilled.

Date 12 Mar 2015

56-day deadline 7 May 2015 est.

Responses identified 2 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Day being

_ (1): Specific leaflets relating to the procedure and aftercare were not handed to the patient: It is understood a "tick box" has now been added t0 documentalion recording that this is done. This will only work if forms are properly and timely completed see below. It is understood training and auditing of forms is now in place, but it is not clear how this is being carried out (2) The Thromboprophylaxis Risk Assessment form was not completed at any point throughout Mrs Tweedy's dealings with the hospital. Had Ihe Risk Assessment been completed this would have flagged up specific risk factors relaling to Mrs Tweedy well before the operation. It was noted the Risk Assessment had not been completed following Mrs Tweedy being anaesthetised and this did start discussion between the Consultant Surgeon overseeing the procedure and the Anaesthetist about the risk factors and action to be taken: However; at this stage in the procedure, it did not allow for a full and proper consideration of Ihe relevant information early on when proper thought could have been given to the risks and potential risks_ (3) Nursing notes on discharge did not fully cover all the factors required to be checked before a patient is discharged: (4) There was no evidence that the Nurse completing the notes had actually seen Mrs Tweedy to discharge (5) The checklist Form for completion on discharge was not completed.

Responses

2 respondents

Norfolk Norwich University Hospitals Education

4 May 2015 PDF

Action Taken

The hospital implemented changes to prescribing practices based on an audit of day case patients, and produced an action plan prior to the inquest. An external inspection confirmed they had implemented the identified actions. (AI summary)

View full response

Dear Mrs Lake Nicola TWEEDY (Deceased) Further to my letter of 23 March, attach a copy of our response to your Report arising from the death of Mrs Tweedy. This is in table form, to ensure that we have addressed each of the issues that you raised: anticipate that the response will be self-explanatory, although some of the issues concerned are complex: If it would be helpful to discuss at all please let us know_ You will appreciate that the question of thromboprophylaxis following case surgery is contentious and the evidence base on which to found best practice is limited, should therefore make clear that the change in prescribing practice introduced by surgeons at our Trust was based on our ongoing audit of 60,000 day case patients over the Iast 5 years rather than on the sad outcome in Mrs Tweedy's individual case_ Rare complications will sometimes occur and there are genuine concerns that increased use of thromboprophylaxis will generate increased risks of bleeding for other patients. We will continue to monitor the position closely. There are always opportunities to learn and, as you know; we produced an action plan in advance of your Inquest in this case_ Recent external inspection has confirmed that we had implemented the actions we had identified in our plan and thal this demonstrated that learning and improvement had taken place" On an administrative point; we understand that copy of your report was also sent to the Department of Health; but it contained a different date for our response to be received: In order to avoid confusion, can confirm that we have responded within the timeframe stated in the original report that you sent to the Hospital.

Department of Health Central Government

11 May 2015 PDF

Noted

The Department acknowledges the concerns and notes the Foundation Trust implemented an action plan. They highlight existing VTE risk assessment tools and data collection, and state NHS England will consider national learning from the case. (AI summary)

View full response

Dear Ms Lake

Thank you for providing the Department with a copy of your Regulation 28 Report following the inquest into the death of Nicola Tweedy. I was very sorry to hear of Mrs Tweedy’s death and wish to extend my sincere condolences to her family.

I understand that you found that Mrs Tweedy died following a rare but recognised risk of surgery for varicose veins. You draw attention to several serious issues that arose during Mrs Tweedy’s stay in hospital which, if addressed, could prevent future deaths from occurring.

I note that you have sent your report to the Norfolk and Norwich University Hospital NHS Foundation Trust. My officials have liaised with the Foundation Trust about your report and I understand that it has fully considered and responded to each of your concerns relating to the care of Mrs Tweedy. I can report that a recent independent external inspection found that the Foundation Trust had implemented an Action Plan, to address the issues raised by this case, and that this demonstrated that learning and improvement had taken place.

I am aware that you sent our Department a copy of your report for interest and were not expecting a direct response. Nevertheless, I would like to take this opportunity to respond to some of the issues that your report raises. I have sought views from officials at NHS England to enable me to do this.

The Department is aware of the importance of reducing the risk of venous thromboembolism (VTE) in hospital patients and the need for all nurses and health care assistants to understand VTE prevention procedures, and the reasons for these procedures. This is why the Department recommends use of a risk assessment checklist and published a VTE risk assessment tool in 2010:

m_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113355.pdf

This tool helps to ensure that assessments take place for every patient, and that results are closely monitored in order to reduce preventable deaths from VTE.

In addition, The National Institute for Health and Care Excellence (NICE) published guidelines in 2010, Venous thromboembolism: reducing the risk. Clinical guideline 92, which offers best

practice advice on reducing the risk of VTE in patients admitted to hospital. The guidelines recommend that all patients, including those admitted for day medical or surgical procedures should be individually assessed for risk of VTE and that the risks and benefits of prophylaxis should be discussed with the patient.

VTE prevention has been recognised as a clinical priority for the NHS by the National Quality Board and the NHS Leadership Team. It has been identified as the most important patient safety practice in our hospitals, and VTE-specific indicators feature in both the NHS Outcomes Framework and the Clinical Commissioning Group Outcomes Indicator Set.

NHS commissioners are required to undertake root cause analysis of all cases of hospital- acquired VTE, in line with the National CQUIN (Commissioning for Quality and Innovation) goal 2013/14, to enable commissioners to address gaps in service provision.

There are a number of levers available to commissioners to ensure that their providers’ maintain patient safety practices in relation to VTE prevention. First and foremost, local commissioners should make certain that they fully utilise the provider payment incentives provided by the national VTE CQUIN Goal 2013/14. There are two indicators that must be met in order to qualify for a single provider payment:-

1) Proportion of all adult inpatients that have been assessed for risk of VTE on admission to hospital must be at least 95%. The commissioners can access quarterly data on the number and proportion of VTE risk assessments carried out by providers and can withhold payment if the threshold is not met; and
2) Root cause analysis should be carried out on all cases of hospital-acquired VTE. The proportion of cases subject to root cause analysis necessary to trigger the CQUIN payment is to be determined locally.

The National VTE Prevention Programme (http://www.vteprevention-nhsengland.org.uk/) publishes data, from NHS England's data collection, on the number of inpatients admitted monthly that have been risk assessed for VTE on admission to hospital, using the criteria in the National VTE Risk Assessment Tool.

Data for VTE Risk Assessment Quarter 4, 2013/14 (January to March 2014) (revised July
2014), shows that the Norfolk and Norwich University Hospitals NHS Foundation Trust, risk- assessed 98.29% of admitted patients for VTE in March 2014.

As a result of this case NHS England has agreed to look at the potential for national learning at the next meeting of the VTE Programme Board. NHS England has also been in direct contact with to reaffirm its commitment to doing everything it can to prevent hospital- associated thrombosis, through the efforts of the National VTE Prevention Programme. It will also update as national initiatives progress.

Lastly, as some of the actions of medical and nursing staff are subject to criticism in your report, I wish to take this opportunity to remind you of the role of the professional regulatory bodies and their fitness-to-practise processes.

As you may be aware, Doctors must register with the General Medical Council (GMC) and Nurses must register with the Nursing and Midwifery Council (NMC) and meet set professional standards to work in the UK and be fit for practise. If an allegation is made about a registrant, who may not meet the professional standards required in the UK, the relevant regulatory body has a duty to investigate and, where necessary, take action to safeguard the

health and well-being of the public. The Department cannot get involved with or comment on individual cases.

I will ensure that a copy of your report and our response is sent to the Care Quality Commission.

I hope that this response is helpful and I am grateful to you for bringing the circumstances of Mrs Tweedy’s death to my attention.

Report sections

Investigation and inquest

On 31 March 2014 | commenced an investigation into the death of NICOLA ANNE TWEEDY, AGE, 54 YEARS The investigation concluded at the end of the inquest on 3 MARCH 2015_ The conclusion of the inquest was medical cause of death: Ia) Pulmonary Embolism b) recent varicose vein surgery and narrative conclusion: Mrs Tweedy died following a rare but recognised risk of appropriate surgery:

Circumstances of the death

Mrs Tweedy was admitted to NNUH for elective varicose vein surgery as a Case patient on 27 March 2014, having seen the Consultant Surgeon on 26 November 2013 and had a pre-operation assessment on 18 March 2014. There was no evidence that Mrs Tweedy had been handed leaflets regarding the procedure and its risks The Risk Assessment form for Thromboprophylaxis was not completed as indicated at this time Despite this noted immediately prior to the procedure, the Risk Assessment form was never completed. Mrs Tweedy was administered a single dose of prophylaxis Following review of data and procedures, NNUH have noted that varicose vein surgery does show an increased risk of DVT relative to other Day Case procedures. It has now been decided to routinely prescribe 5 days of thromboprophylaxis to all patients undergoing varicose vein surgery unless there are contra-indications_ Following the procedure Mrs Tweedy was taken to the Recovery Ward where she was deemed appropriate for Nurse led discharge. Notes were made by a Nurse recording she had passed urine and eaten supper: Before discharge, a Palient is required to be shown to have eaten and had a drink; passed urine, is able to get up and walk, not feel nauseous_ had adequate pain relief and understood instructions for care following discharge: A checklist form for completion on discharge had not been completed: Iraised concerns that his wife was not fit for discharge with a Nurse (it may well have been to a different Nurse) in that she had only walked 10 _ 15 paces and left in a wheelchair. On 29 March 2014, Mrs Tweedy was found collapsed and died at her home.

Action should be taken

In my opinion action should be taken t0 prevent future dealhs and believe your organisation has the power to take such action:

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Shared signals

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Report details

Reference: 2015-0095
Date of report: 12 March 2015
Coroner: Jacqueline Lake
Coroner area: Norfolk

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: 7 May 2015 (estimated).

Sent to

Norfolk and Norwich University Hospital NHS Foundation Trust

Source links

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Data: judiciary.uk under OGL.