Dear Assistant Coroner, Response from the Scottish Dental Clinical Effectiveness Programme, NHS Education for Scotland, to the Regulation 28 Report received from Derby and Derbyshire Coroner’s Office on 11 September 2024 Regarding the death of Derek Hand, the Assistant Coroner’s report noted the following concern: My concern is that as the current guidance does not require any further checks for patients on Clopidogrel prior to dental procedures there is a risk of other patients on Clopidogrel experiencing excess bleeding following dental procedures. It would be of assistance to know whether: a) Has any thought been given to requiring an INR test or any other form of blood test to detect a risk of excess bleeding for patients on Clopidogrel prior to dental procedures? b) If it has not, is there a reason for this? Firstly, NHS Education for Scotland (NES) would like to extend its sincere sympathies to Mr Hand’s wife and family. The Scottish Dental Clinical Effectiveness Programme (SDCEP) is part of NES. Working in collaboration with dental and medical clinical experts, SDCEP develops dental clinical guidance that is based on the available evidence taking into consideration the benefits versus harms, practicalities, and patient and practitioner views. Although developed within NHS Scotland, SDCEP guidance is used across the UK to inform dental practice. As guidance, the information presented does not override the healthcare professional’s right, and duty, to make decisions appropriate to each patient, with the patient’s valid consent. Therefore, clinical decisions will be based on the individual patient and their clinical history.

In response to the queries from the Assistant Coroner, SDCEP can confirm that blood tests to detect a risk of excess bleeding for patients taking clopidogrel or other antiplatelet drugs were considered during the development of the Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs guidance. Based on expert clinical opinion and published advice, the guidance notes in Section 8 that “There is no suitable test equivalent to the INR for measuring the antiplatelet effect of the various drugs that patients may be taking.” Clopidogrel acts by interfering with platelet activation, reducing the ability of platelets to aggregate and form a clot. The INR (International Normalised Ratio) test, used to monitor patients taking warfarin, measures the activation of coagulation factors and is not an indicator of platelet function, so cannot be used to monitor the effects of clopidogrel. In response to the Coroner’s Report, SDCEP has taken further clinical specialist advice which confirms that it is still the case that there is no available blood test that would reliably predict a risk of excessive bleeding for a patient taking clopidogrel. The next review of the guidance is scheduled to commence in 2027. However, if SDCEP becomes aware of any significant developments before the scheduled review, an earlier review may be triggered. During the scheduled review, any new evidence or changes in expert clinical opinion relating to the Assistant Coroner’s concerns will be considered to check whether the situation has changed.