Source · Prevention of Future Deaths

Phyllis Kerry

Ref: 2014-0457 Date: 23 Oct 2014 Coroner: Heidi Connor Area: Nottinghamshire 2 responses identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted a lack of clear guidelines for managing intra-cerebral bleeds in patients on Warfarin, an absence of clarity on specialty responsibility for reversal decisions, and insufficient communication of relevant guidelines to staff.

Date 23 Oct 2014

56-day deadline 19 Dec 2014 stated in the report

Responses identified 2 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner noted a lack of clear guidelines for managing intra-cerebral bleeds in patients on Warfarin, an absence of clarity on specialty responsibility for reversal decisions, and insufficient communication of relevant guidelines to staff.

View full coroner's concerns

_ (1) Which specialty takes responsibility for deciding when immediate reversal is needed? (2) The absence of clear guidelines for dealing with patients presenting with intra-cerebral bleeds whilst on Warfarin or similar medication: (3)The communication of relevant guidelines to relevant staff While none of the witnesses heard from were aware of any relevant guidelines, it is possible that these may in fact already be in existence_ Similarly, it may be that draft guidelines are reviewed_ However it was not clear from the evidence when these would be finalised_ If there are existing guidelines_ it would concern me greatly that the witnesses heard from were unaware of these, and take the view that communication of guidelines is as important as the guidelines themselves_

Responses

2 respondents

Nottingham University Hospitals NHS Trust

NHS Trust

Indexed date: 16 Dec 2014 PDF

AI-classified response stance Action Planned

AI-generated response summary

• Discussions were held between relevant specialties to optimise the management of patients with intra-cerebral bleeds. • A new guideline has been prepared to provide more rapid intervention in anticoagulation management and clarify specialty responsibility. • The guideline is undergoing consultation and is expected to be circulated by early 2015, with a request for it to be added to the NUH guideline APP.

View full response

Dear Mrs Connor

Re: Preventing Future Deaths Notice – Phyllis Kerry

On behalf of Nottingham University Hospitals I am responding to the regulation 28 PFD notice issued following the inquest into the death of Phyllis Kerry.

Thank you for bringing this important issue to our attention. Our inquiries have agreed with your observation of a lack of clarity with regard to the reversal of anticoagulation in patients admitted with intracerebral haemorrhage, and also which specialty has ownership of this management.

Discussions have been held between the specialties involved to optimise the management of these patients. This has included senior representation from the Emergency Department, Neurosurgery, Stroke services and Haematology. This discussion has referred to the 2008 NICE guidance on the management of acute stroke patients.

A new guideline has been prepared which I am confident will provide more rapid intervention in the management of anticoagulation and will clarify which specialty is responsible for this element of care.

The specialties involved are currently consulting with colleagues to finally agree the guideline and am conscious that this may not complete by the 19 December 2014 when the PFD response is required. I am confident that the guideline will be ready for circulation by the start of 2015.

In addition to sharing with medical staff in the appropriate specialties we will also ask for this guideline to be added to the NUH guideline APP which will assist medical staff to access the guideline whenever required.

I hope that these actions will provide assurance that NUH have taken appropriate steps to improve the management and safety of our patients, and to attend to the requirements of this PFD notice.

I will send you the agreed guideline as soon as it is available, or if you prefer I can send the version currently under discussion.

Please let me know if I can provide any additional information.

NUH Deputy Medical Director

Nottingham University Hospitals NHS Trust2f

NHS Trust

Indexed date: 27 Jan 2015 PDF

AI-classified response stance Action Taken

AI-generated response summary

• A new guideline for the prompt and appropriate treatment of patients on Warfarin presenting with Intra Cranial Haemorrhage has been agreed and provided. • Heads of Service have been asked to ensure the new guideline is communicated to all current medical staff and included in specialty induction for new staff. • The NUH guideline group has been asked to consider including the guidance within the NUH guideline APP.

View full response

Dear Mrs Connor Inquest Touching the Death of Phyllis Kerry The new guideline to assist with the prompt and appropriate treatment of patients who are on warfarin presenting with Intra Cranial Haemorrhage has now been agreed by all parties involved and accompanies this letter. I am confident that this guidance will support the NUH staff in managing these patients and reduce delays to urgent treatment. I have asked the Heads of Service for the specialties involved (ED, Stroke Services, Neurosurgery, Haematology) to ensure that this new guideline is communicated to all current medical staff, both trainee and Consultant. This communication will be reviewed by the Medical Directors office to ensure that it is progressed appropriately. I have also asked for this issue to be included in medical staff specialty induction in order to ensure that new staff will also be made aware. I have also asked the NUH guideline group to consider other ways of making the guidance readily available, in particular this will be considered for inclusion within the NUH guideline APP which has widespread use within the NUH. I trust that these measures will assure you of our response to the PFD issued in this respect. If I can provide any further information please let me know

Kind regards Deputy Medical Director, NUH.

Report sections

Investigation and inquest

On 11 July 2014, commenced an investigation into the death of Phyllis Kerry, DoB 8 June 1935_ The investigation concluded at the end of the inquest on 22 October 2014. The conclusion of the inquest was that the cause of death was 1a Primary intracerebral haemorrhage 1b Warfarin Treatment 1c Metallic aortic valve and aortic root replacement ascending aortic aneurysm 2 Hypertension recorded a narrative conclusion as follows Phyllis died after suffering a stroke, which was complicated by the Warfarin medication she was on.

Circumstances of the death

Mrs had a history of heart valve replacement and aortic aneurysm and was on long-term Warfarin. She was admitted to the ED at Queen's Medical Centre at 1555 hrs on 28"h January 2104, with symptoms suggestive of stroke. She was taken for a CT scan at 1733 The scan showed a bleed consistent with haemorrhagic stroke ED consultant liaised with neurosurgery and haematology colleagues. Neurosurgery advice was that nothing could be done surgically, but that the effects of the Warfarin should be reversed, and should be contacted again if her condition deteriorated . The haematology registrar advised giving Mrs Vitamin K to reverse the Warfarin He did not recommend giving Octaplex He did not discuss the case with his seniors Or with neurosurgery colleagues. It was accepted in evidence that Octaplex should have been given, to reduce the effects of the Warfarin more quickly. Mrs deteriorated, with dropping GCS, and further CT scanning showed that her bleed had increased significantly: After consultation with neurosurgery colleagues, and discussion with her family, DNAR order was put in place and Mrs died her death being confirmed in the early hours of 31 January 2014. The_haematology registrar gave evidence_that he carried out research of his own on 28 To Kerry Kerry Kerry hrs_ The they Kerry Kerry Kerry

January, using Electronic Medicines Compendium, and came to the conclusion that;, because of a risk of clotting; would be better for Mrs to be given Vitamin K instead of Octaplex: took evidence a consultant physician, who said that NICE and RCP guidelines state that both Vitamin K and Octaplex should be given in cases of intracerebral haemorrhage in patients anti-coagulated with Warfarin or similar drugs_ The haematology registrar was not aware of these guidelines, ad the consultant physician told us that there are no current trust guidelines which cover this draft guidelines have been withdrawn but not replaced. Lalso heard that consultant haematologist not involved with this patient; has reviewed the case and advised all haematology and neurosurgery ST doctors that the responsibility for a decision for immediate reversal of Warfarin in patients with CNS bleeds lies with neurosurgery. gave evidence that he does not consider this practice has been adopted that it is simply suggestion and he does not agree that neurosurgery advice is always necessary in cases like this. It is clear that there would need to be involvement from several specialties in relation to prescribing Octaplex in particular. Crucially, however, could not be clear; from the evidence heard, which specialty would ultimately be responsible for deciding when immediate reversal is called for. It was also clear that there was no guideline or protocol in place which the haematology registrar could_have consulted

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:

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Report details

Reference: 2014-0457
Date of report: 23 October 2014
Coroner: Heidi Connor
Coroner area: Nottinghamshire

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: 19 Dec 2014 (stated in the report).

Sent to

Nottingham University Hospitals NHS Trust

Source links

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Data: judiciary.uk.

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