John Parry
PFD Report
All Responded
Ref: 2024-0347
All 1 response received
· Deadline: 22 Aug 2024
Coroner's Concerns (AI summary)
The practice of doctors prescribing warfarin based solely on nurse-provided information, without consulting full patient records, creates a risk of incomplete data and unsafe dosing.
View full coroner's concerns
The evidence heard raised a concern about the safe prescribing of warfarin. When a doctor is asked by a nurse to dose the warfarin, the accepted practice is that the doctor relies on the nurse to give all relevant information and the doctor only checks the INR blood results from the laboratory. There is no requirement or expectation that the doctor looks at the patient’s medical records or seeks information about the patient. At the inquest evidence was heard that the nurse had not communicated all relevant information. Although in this case it did not have an adverse outcome, it was accepted that there was a risk that if a doctor does not have all relevant information, warfarin could be prescribed and administered and there could be a risk of death. Evidence was given that this lack of appropriate communication was believed to be unusual but it was accepted that it is not necessarily known how unusual because it would probably only become apparent in cases of an adverse outcome.
Responses
Action Taken
The importance of communication regarding anticoagulation has been re-emphasised, and the learning from the case shared with ward leaders and matrons. The daily brief includes a reminder about clear information. Warfarin prescribing has been incorporated into the digital system, and by December 2025, a digital reminder will be embedded for MDT colleagues to include pertinent clinical information on digital warfarin dosage requests. (AI summary)
The importance of communication regarding anticoagulation has been re-emphasised, and the learning from the case shared with ward leaders and matrons. The daily brief includes a reminder about clear information. Warfarin prescribing has been incorporated into the digital system, and by December 2025, a digital reminder will be embedded for MDT colleagues to include pertinent clinical information on digital warfarin dosage requests. (AI summary)
View full response
Dear Professor Mason
Thank you for your Regulation 28 Report dated 27th June 2024, which arose out of your inquest into the death of Mr John Parry.
Whilst it was acknowledged that it did not have an adverse outcome, you were understandably concerned about the potential impact on patients which might result from ineffective communication among the treating clinical team.
We fully accept and recognise the paramount importance of communication between all members of the multidisciplinary team in ensuring safe and effective patient care.
Following on from the issues raised in your Regulation 28 Report we have re-emphasised the importance of clear and effective communication between all colleagues in particular regarding anticoagulation. This includes sharing learning from this case with all ward leaders, matrons and through our chief nurse forums. A reminder to all clinical teams via the daily brief of the importance of giving clear information was included in the week commencing 29/07/24 and was repeated in the week commencing 05/08/24. The daily brief has three key messages and is read out to all clinical teams at every huddle every day for a week. We are also developing our electronic patient record system to enable clinicians to review all available information about a patient on one system. Earlier this year we successfully deployed electronic clinical notation in our emergency department and aim to roll this across our inpatient areas pending additional developments of the system with the vendor. In addition, we have now incorporated warfarin prescribing into our digital system allowing clinicians access to more information about the patient without having to log-into another system. As we further roll out electronic notation, clinicians will increasingly be able to access more information about the patient in one system. To help improve communication further, we will embed a digital reminder for all MDT colleagues to include pertinent clinical information or any changes to the patient’s condition when generating a digital warfarin dosage request for the patient. Due to a need to ensure appropriate testing and governance, these changes will take time to fully implement across the whole of UHL, but we anticipate this will occur by December 2025. Our eHospital team, which is chaired by our Medical Director will oversee these changes. I trust that this gives you assurance that we take this matter very seriously as we look to strengthen our processes and make them more robust.
If you wish for any further information, please do not hesitate to contact me.
Thank you for your Regulation 28 Report dated 27th June 2024, which arose out of your inquest into the death of Mr John Parry.
Whilst it was acknowledged that it did not have an adverse outcome, you were understandably concerned about the potential impact on patients which might result from ineffective communication among the treating clinical team.
We fully accept and recognise the paramount importance of communication between all members of the multidisciplinary team in ensuring safe and effective patient care.
Following on from the issues raised in your Regulation 28 Report we have re-emphasised the importance of clear and effective communication between all colleagues in particular regarding anticoagulation. This includes sharing learning from this case with all ward leaders, matrons and through our chief nurse forums. A reminder to all clinical teams via the daily brief of the importance of giving clear information was included in the week commencing 29/07/24 and was repeated in the week commencing 05/08/24. The daily brief has three key messages and is read out to all clinical teams at every huddle every day for a week. We are also developing our electronic patient record system to enable clinicians to review all available information about a patient on one system. Earlier this year we successfully deployed electronic clinical notation in our emergency department and aim to roll this across our inpatient areas pending additional developments of the system with the vendor. In addition, we have now incorporated warfarin prescribing into our digital system allowing clinicians access to more information about the patient without having to log-into another system. As we further roll out electronic notation, clinicians will increasingly be able to access more information about the patient in one system. To help improve communication further, we will embed a digital reminder for all MDT colleagues to include pertinent clinical information or any changes to the patient’s condition when generating a digital warfarin dosage request for the patient. Due to a need to ensure appropriate testing and governance, these changes will take time to fully implement across the whole of UHL, but we anticipate this will occur by December 2025. Our eHospital team, which is chaired by our Medical Director will oversee these changes. I trust that this gives you assurance that we take this matter very seriously as we look to strengthen our processes and make them more robust.
If you wish for any further information, please do not hesitate to contact me.
Sent To
- University Hospitals of Leicester NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
22 Aug 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 16 November 2023 I commenced an investigation into the death of John Kenneth PARRY aged
72. The investigation concluded at the end of the inquest on 26 June 2024. The conclusion of the inquest was that: Following the falls on the 6th July 2023 Mr Parry was commenced on neurological observations. However, they were not carried out in accordance with the hospital trust policy. In addition, the calculations were inaccurate. As a result, no reliance could be placed on the observation recordings. Medical evidence also makes it clear that Mr Parry should have had a CT head scan within one hour of his fall. Had this been carried out, on a balance of probabilities, the intracranial bleed could have been detected sooner and there would have been a chance of reducing the mortality risk and achieving a better outcome. The cause of death was established as: I a Spontaneous Intracerebral Haemorrhage I b I c II Mitral Valve Disease (On Anticoagulation)
72. The investigation concluded at the end of the inquest on 26 June 2024. The conclusion of the inquest was that: Following the falls on the 6th July 2023 Mr Parry was commenced on neurological observations. However, they were not carried out in accordance with the hospital trust policy. In addition, the calculations were inaccurate. As a result, no reliance could be placed on the observation recordings. Medical evidence also makes it clear that Mr Parry should have had a CT head scan within one hour of his fall. Had this been carried out, on a balance of probabilities, the intracranial bleed could have been detected sooner and there would have been a chance of reducing the mortality risk and achieving a better outcome. The cause of death was established as: I a Spontaneous Intracerebral Haemorrhage I b I c II Mitral Valve Disease (On Anticoagulation)
Circumstances of the Death
John Parry was a 72-year-old male who was admitted to the Leicester Royal Infirmary via the Emergency Department on the 4th July 2023. He presented with feeling unwell for six weeks, a headache for one month, weight loss and an increased urinary frequency for a few days prior to admission. He was appropriately investigated but no conclusive diagnosis was made regarding the cause. On the 6th July 2023 Mr Parry had two unwitnessed falls. Later that day his condition deteriorated and following a CT scan of his head a spontaneous bleed was diagnosed. In consultation with the neurosurgeons at the Queens Medical Centre, Nottingham it was decided that Mr Parry was not suitable for surgical intervention and the decision was made to commence Mr Parry on palliative care. He died on the 7th July 2023.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.