Kenneth Evans
PFD Report
All Responded
Ref: 2017-0175
All 1 response received
· Deadline: 29 Sep 2017
Response Status
Responses
1 of 1
56-Day Deadline
29 Sep 2017
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns AI summary
Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the patient.
Responses
Response received
View full response
Dear Mr Siddique, Regulation 28 report
— Mr Kenneth Evans The circumstances of this failure to implement our existing policy were unusual in that the patient had been due for discharge from the acute service and because of a series of repeated delays in his discharge plans he was subsequently transferred to an intermediate care area of the hospital supervised by primary care physicians
— Evergreen, and, therefore, had not been reassessed for VTE prophylaxis during this prolonged discharge journey. The Evergreen area is an intermediate care area where patients are admitted following discharge from the acute trust. These beds are utilised for patients who need nursing care but who are otherwise medically fit (analogous to nursing home patients). Following this incident we have made it clear to all staff that Evergreen is part of our services and thus subject to our Trust policy on VTE assessments. I have enclosed the Trusts policy for venous thromboprophylaxis (VTE) for your information as part of the Policy there is detail on how we monitor compliance with this Policy (contained within Appendix 1 of the Policy). Currently compliance in undertaking a VTE assessment for prophylaxis is at 93% for the Trust. All members of clinical staff are trained in the assessment of patients for VTE prophylaxis as part of their mandatory training.
Awareness & the need for VTE assessments has been discussed with our medical teams and following your letter to the Trust is timetabled to be raised again at the next mandatory Medicine Audit meeting with this specific case being presented to the multidisciplinary teams attending. On a further note due to the changing pattern & patient demand we are reconfiguring the Evergreen area to re-designate the beds as acute and these will be looked after by consultant medical staff. I hope that the above gives you confidence that whilst this failing was a result of a series of unusual events regarding Mr Evans discharge we have taken steps to remove any possible ambiguity in respect of undertaking a VTE assessment in accordance with our established and audited policy for all areas of the hospital.
— Mr Kenneth Evans The circumstances of this failure to implement our existing policy were unusual in that the patient had been due for discharge from the acute service and because of a series of repeated delays in his discharge plans he was subsequently transferred to an intermediate care area of the hospital supervised by primary care physicians
— Evergreen, and, therefore, had not been reassessed for VTE prophylaxis during this prolonged discharge journey. The Evergreen area is an intermediate care area where patients are admitted following discharge from the acute trust. These beds are utilised for patients who need nursing care but who are otherwise medically fit (analogous to nursing home patients). Following this incident we have made it clear to all staff that Evergreen is part of our services and thus subject to our Trust policy on VTE assessments. I have enclosed the Trusts policy for venous thromboprophylaxis (VTE) for your information as part of the Policy there is detail on how we monitor compliance with this Policy (contained within Appendix 1 of the Policy). Currently compliance in undertaking a VTE assessment for prophylaxis is at 93% for the Trust. All members of clinical staff are trained in the assessment of patients for VTE prophylaxis as part of their mandatory training.
Awareness & the need for VTE assessments has been discussed with our medical teams and following your letter to the Trust is timetabled to be raised again at the next mandatory Medicine Audit meeting with this specific case being presented to the multidisciplinary teams attending. On a further note due to the changing pattern & patient demand we are reconfiguring the Evergreen area to re-designate the beds as acute and these will be looked after by consultant medical staff. I hope that the above gives you confidence that whilst this failing was a result of a series of unusual events regarding Mr Evans discharge we have taken steps to remove any possible ambiguity in respect of undertaking a VTE assessment in accordance with our established and audited policy for all areas of the hospital.
Report Sections
Investigation and Inquest
On the 16 MarcF 2017 ommenced an mvesbgator nto the death of the late Mr Kenneth Evans The nvestgabon conc uded at the end of tFe nquest on 0 May 2017 The conclus n f the mquest was a arrat ye concl SlO Mr Evans had a fal at home aid he fratured hs p ibc amus He was adrntted to Russells Hall hosprta on the 27 February 2017 and r rsk assessment for developwg lots was u ide lake i He subsequent y developed a pu monary embolus and ded on the 11 March 20 7 Ihere was a falure to nsk asses im for clots and also rissed opportuntes to admnster hepann to mm mse the sk of develop ng a pulmonary embolus and these were gr ss fa ures n basc med cal are g v ng nse to neglect It e ca se of deatF vas a Pulmora y Embo us b rimobhty c Mecanica a F THE DEATH
secondary Left Ventricular mpawment Ths s ar n-dcahon for thrombolyss so he was given Alteplase at 17.00 and started on an IV Heparin infusion. v) A further MET caM was put out at 17 45 as he had become pen-arrest (low oxygen levels and hypotenson). He subsequently arrested (PEA rhythm) requiring Advanced Life Support. The total hme without a cardiac output was around 20 minutes before return of spontaneous circulation. He was then admtted to the lntenstve Care Unit for or-going management v; The next morning he needed ncreasing amounts of adrenaline and became unstable The family had been fully informed of diagnosis. management and his poor prognosis. After continued period of hypotension the decision was taken to stop active treatments and focus on the patients comfort and digmty Sadly he passed away on the 11 March 2017
secondary Left Ventricular mpawment Ths s ar n-dcahon for thrombolyss so he was given Alteplase at 17.00 and started on an IV Heparin infusion. v) A further MET caM was put out at 17 45 as he had become pen-arrest (low oxygen levels and hypotenson). He subsequently arrested (PEA rhythm) requiring Advanced Life Support. The total hme without a cardiac output was around 20 minutes before return of spontaneous circulation. He was then admtted to the lntenstve Care Unit for or-going management v; The next morning he needed ncreasing amounts of adrenaline and became unstable The family had been fully informed of diagnosis. management and his poor prognosis. After continued period of hypotension the decision was taken to stop active treatments and focus on the patients comfort and digmty Sadly he passed away on the 11 March 2017
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