Source · Prevention of Future Deaths

David Bladen

Ref: 2015-0079 Date: 4 Mar 2015 Coroner: Nicola Mundy Area: South Yorkshire (East) 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner identified an absence of guidance for optimal thromboprophylaxis management in patients with restricted mobility due to a brace, particularly when they are not in casts.

Date 4 Mar 2015

56-day deadline 29 Apr 2015 est. estimated from the report date

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner identified an absence of guidance for optimal thromboprophylaxis management in patients with restricted mobility due to a brace, particularly when they are not in casts.

View full coroner's concerns

(1) Absence of guidance for optimum thromboprophylaxis management in patients who are not in casts but still have restriction of mobility eg. due to a brace. Coroner'$ Court and Office; Doncaster Crown Court; Road, Doncaster; DNI 3HS Tel 01302 320844 Fax 01302 364833 City falling being from College

Responses

1 respondent

National Institute for Health and Care Excellence

Other

PDF

AI-classified response stance Noted

AI-generated response summary

• The Guideline Development Group agreed a research recommendation to increase knowledge regarding post-operative care. • The guideline is to be updated as part of a routine surveillance process, and a new scope will be prepared. • Arrangements will be made to forward the report to guideline developers to inform them of the case circumstances and concerns.

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Dear your have they they

It is worth noting that ' the wording used in the recommendations in our clinical guidelines denotes the strength of the recommendation. On this occasion we have said that clinicians should 'consider' offering pharmacological VTE prophylaxis to patients with lower limb casts after evaluation of the risks The use of the term 'consider' means that we are confident that the intervention will be beneficial; however it also reflects some uncertainty in this area. Following consideration of the evidence, the orthopaedic subgroup of the Guideline Development Group (GDG) were unsure whether pulmonary embolism would have occurred with or without VTE prophylaxis in this circumstance_ Due to the uncertainty in the evidence base the GDG agreed research recommendation to increase our knowledge of this aspect of post-operative care. As of our routine surveillance process, this guideline is to be updated and a new scope will be prepared as part of the process: We have not yet scheduled this project into our work programme, however will make arrangements for a copy of report to be forwarded to guideline developers at the appropriate time so that are aware of the circumstances around this case and your concerns about the lack of specific guidance for patients in brace. Please let me know if you or Mr Bladen's family would prefer that this information should not be shared_ hope this information is helpful to you:

Report sections

Investigation and inquest

On 04/09/2014 | commenced an investigation into the death f David Andrew Bladen, 58 The investigation concluded at the end of the inquest on 13 January 2015. The conclusion of the inquest was Narrative conclusion. The cause of death was 1a. Pulmonary embolism 1b. Deep vein thrombosis Ic. Ruptured right quadriceps (Operated in July 2014)

Circumstances of the death

Mr Bladen ruptured his quadriceps tendon after down some stairs on 14th July 2014. He underwent surgery to reconstruct the right quadriceps tendon. He was provided with mechanical thromboprophylaxis during surgery and post operatively received two doses of medication thromboprophylaxis before discharged two days post surgery: He was prescribed no extended prophylactic treatment on discharge and further assessments led to no further treatment being provided for thromboembolism . Mr Bladen died on 2nd September 2014 from a massive pulmonary embolism. During the course of evidence not only heard doctors who had been involved in Mr Bladen's care and the issue of thromboprophylaxis but also from a specialist in this area It became clear during the evidence heard that although NICE provides guidance in relation to the need for extended prophylaxis in certain cases e.g where a patient has been given as cast, there is no clear guidance for patients in a brace. (As was the case with Mr Bladen) and there are many arguments to say that such patients are at as much risk as developing thromboembolism as those with casts_ Medics who gave evidence at the inquest were in agreement that the NICE guidelines does not provide advice as t0 what is the best thromboprophylaxis management for these categories of patients_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you National Institute For Health And Care Excellence have the power to take such action_

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Report details

Reference: 2015-0079
Date of report: 4 March 2015
Coroner: Nicola Mundy
Coroner area: South Yorkshire (East)

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: 29 Apr 2015 (estimated from the report date).

Sent to

National Institute for Health and Care Excellence

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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