John James
PFD Report
All Responded
Ref: 2023-0242
All 1 response received
· Deadline: 6 Sep 2023
Response Status
Responses
1 of 1
56-Day Deadline
6 Sep 2023
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
The refusal of anti-coagulation medication was not brought to the attention of medical staff. The administration of anti-coagulation medication to patients like Mr James, is vital for reducing the risk of a venous thrombo-embolism, a potentially life-threatening condition. There is no electronic prompt/alert to highlight to the medical team when prescribed anticoagulation medication is not administered.
The Trust’s internal investigator recognised that a fail-safe should be put in place within the electronic records, to ensure escalation to the medical team where doses of prescribed anti-coagulation are not administered. Such a measure could prevent similar deaths from occurring. It was considered that this measure could assist in preventing future deaths not just locally, but at a wider level.
The Trust’s internal investigator recognised that a fail-safe should be put in place within the electronic records, to ensure escalation to the medical team where doses of prescribed anti-coagulation are not administered. Such a measure could prevent similar deaths from occurring. It was considered that this measure could assist in preventing future deaths not just locally, but at a wider level.
Responses
Barts Health NHS Trust will update Millennium training to ensure multi-professional teams know how to use the electronic prescribing system's flag for delayed medication. They are also developing a medicines safety dashboard to provide data on dose omission and support quality improvement programs across the Trust.
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Dear HM Coroner, Thank you for your letter dated 11th July 2023 following the inquest of Mr John James detailing concerns arising from the evidence presented and inviting the Trust to consider the implementation of changes to reduce the risk of future harm or death. The Prevention of Future Death report has been reviewed at the Whipps Cross Hospital Board and Divisional Board to agree actions that will be adopted across the Barts Health group. Your concerns
1. The refusal of anti-coagulation medication was not brought to the attention of medical staff. The administration of anti-coagulation medication to patients like Mr James, is vital for reducing the risk of a venous thrombo-embolism, a potentially life-threatening condition. There is no electronic prompt/alert to highlight to the medical team when prescribed anticoagulation medication is not administered. In cases where a patient declines critical medication e.g., VTE prophylaxis, anti-seizure medication, documentation must be very clear that the patient has capacity to understand the risks associated with this decision. Learning from this serious incident investigation has been shared across the organisation as part of the standard post investigation process to share learning across the group.
2. The Trust’s internal investigator recognised that a fail-safe should be put in place within the electronic records, to ensure escalation to the medical team where doses of prescribed anti- coagulation are not administered. Such a measure could prevent similar deaths from occurring. It was considered that this measure could assist in preventing future deaths not just locally, but at a wider level. Our response: The electronic prescribing and medicines administration system (ePMA) currently has functionality (all of which is accessible via Millennium®) to reduce harm associated with missed or late medication administration. This includes visual aids in the form of a red tile if a dose is delayed by more than 2 hours. This visual flag is available to all users. Millenium training will be updated to reflect learning from this case to ensure that multi-professional teams know how to use the flag system to ensure critical medications are not omitted. Minimising medication dose omissions is a Trust medicines safety improvement priority supported by the trust Medicines Safety Committee. A medicines safety dashboard is being developed and will provide data on dose omission over a given period. The information will be used to track each ward's performance and to support quality improvement programmes across the Trust on dose omission. Actions in relation to this letter and evidence of completion will be presented at the Whipps Cross Quality and Safety Committee and by exception to the Trust Quality Assurance Committee. The Trust deeply regrets that the serious incident investigation report and associated action plan did not provide HM Coroner and the patient’s family with sufficient assurance around the actions implemented. Arrangements will be made to share this letter with the patient’s family and an offer will be extended to them to meet with senior clinicians to discuss any questions, concerns or additional learning and improvement that the Trust should implement in light of the death Mr John James. If you have any further comments or questions, please do not hesitate to contact me.
1. The refusal of anti-coagulation medication was not brought to the attention of medical staff. The administration of anti-coagulation medication to patients like Mr James, is vital for reducing the risk of a venous thrombo-embolism, a potentially life-threatening condition. There is no electronic prompt/alert to highlight to the medical team when prescribed anticoagulation medication is not administered. In cases where a patient declines critical medication e.g., VTE prophylaxis, anti-seizure medication, documentation must be very clear that the patient has capacity to understand the risks associated with this decision. Learning from this serious incident investigation has been shared across the organisation as part of the standard post investigation process to share learning across the group.
2. The Trust’s internal investigator recognised that a fail-safe should be put in place within the electronic records, to ensure escalation to the medical team where doses of prescribed anti- coagulation are not administered. Such a measure could prevent similar deaths from occurring. It was considered that this measure could assist in preventing future deaths not just locally, but at a wider level. Our response: The electronic prescribing and medicines administration system (ePMA) currently has functionality (all of which is accessible via Millennium®) to reduce harm associated with missed or late medication administration. This includes visual aids in the form of a red tile if a dose is delayed by more than 2 hours. This visual flag is available to all users. Millenium training will be updated to reflect learning from this case to ensure that multi-professional teams know how to use the flag system to ensure critical medications are not omitted. Minimising medication dose omissions is a Trust medicines safety improvement priority supported by the trust Medicines Safety Committee. A medicines safety dashboard is being developed and will provide data on dose omission over a given period. The information will be used to track each ward's performance and to support quality improvement programmes across the Trust on dose omission. Actions in relation to this letter and evidence of completion will be presented at the Whipps Cross Quality and Safety Committee and by exception to the Trust Quality Assurance Committee. The Trust deeply regrets that the serious incident investigation report and associated action plan did not provide HM Coroner and the patient’s family with sufficient assurance around the actions implemented. Arrangements will be made to share this letter with the patient’s family and an offer will be extended to them to meet with senior clinicians to discuss any questions, concerns or additional learning and improvement that the Trust should implement in light of the death Mr John James. If you have any further comments or questions, please do not hesitate to contact me.
Report Sections
Investigation and Inquest
On 16 February 2023 I commenced an investigation into the death of Mr John Michael James. The investigation concluded at the end of the inquest on the 6 July 2023. The conclusion of the inquest was a narrative conclusion:
Mr. James died as a result of a pulmonary embolism during the course of a lengthy hospital admission. He was at very high risk of developing a venous thromboembolism. There were three missed doses of anti-coagulation medication in the two weeks leading up to his death.
Mr. James died as a result of a pulmonary embolism during the course of a lengthy hospital admission. He was at very high risk of developing a venous thromboembolism. There were three missed doses of anti-coagulation medication in the two weeks leading up to his death.
Circumstances of the Death
Mr. James was admitted to Whipps Cross Hospital on the 13 October 2022 and was found to be suffering from malnutrition and a bowel obstruction (later discovered to be due to an adenocarcinoma). He underwent surgery on 18 October 2022 to remove the tumour. This was surgically uneventful. Post-operatively, he required a lengthy period of intensive care. On the 19 December 2022 he was stepped down from intensive care to a ward. He was at a very high risk of developing a thromboembolism due to his cancer diagnosis, recent surgery, lengthy period in hospital and immobility. During the period of 9 to 15 January 2023 he refused his anti-coagulation medication on three occasions. The reason for refusal is unclear and there is no documented evidence that the risk of non-compliance with the medication was explained to him or escalated to the medical team. On the 20 January 2023, Mr. James suffered from an acute deterioration in his health, culminating in a cardiac arrest. He passed away at Whipps Cross Hospital on the 21 January 2023 from a pulmonary embolism. The missing doses of anticoagulation during the two weeks leading up to his death is likely to have contributed to a degree, to the development of the pulmonary embolism.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.