Michael Briggs
PFD Report
All Responded
Ref: 2024-0208
All 1 response received
· Deadline: 13 Jun 2024
Coroner's Concerns (AI summary)
Dentists in England and Wales face limited and conflicting guidance on antibiotic prophylaxis for patients at high risk of infective endocarditis, leading to inconsistency and potential patient harm.
View full coroner's concerns
Regulation 28 – After Inquest CONTROLLED Document Template Updated 30/07/2021
The matters of concern arise in the context of patients who are at increased risk of infective endocarditis following dental procedures and whether such patients should be given antibiotic prophylaxis. At inquest the court heard evidence that there is limited guidance available for dentists in England and Wales on how to manage such patients. The evidence heard at inquest gives rise to the following matters of concern:
• The NICE guideline GC64 “Prophylaxis against infective endocarditis” states that antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures. The guideline does not provide any implementation advice for dentists on how they should manage patients who are at an increased risk.
• The Scottish Dental Clinical Effectiveness Programme (SDCEP) produced implementation advice in August 2018 entitled “Antibiotic Prophylaxis Against Infective Endocarditis”. The document contains a “NICE Statement of Endorsement” that the advice supports the implementation of recommendations in GC64. There is no reciprocal endorsement or mention of the SDCEP advice in GC64 and there does not appear to be any such implementation advice applicable to dentists in England and Wales.
• In 2023 the European Society of Cariology (ESC) produced Clinical Practice Guidelines for the management of endocarditis which recommends antibiotic prophylaxis for high risk individuals. The court heard evidence that cardiologists in England and Wales are regularly following this guidance which conflicts with the 2016 NICE guideline.
The matters of concern arise in the context of patients who are at increased risk of infective endocarditis following dental procedures and whether such patients should be given antibiotic prophylaxis. At inquest the court heard evidence that there is limited guidance available for dentists in England and Wales on how to manage such patients. The evidence heard at inquest gives rise to the following matters of concern:
• The NICE guideline GC64 “Prophylaxis against infective endocarditis” states that antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures. The guideline does not provide any implementation advice for dentists on how they should manage patients who are at an increased risk.
• The Scottish Dental Clinical Effectiveness Programme (SDCEP) produced implementation advice in August 2018 entitled “Antibiotic Prophylaxis Against Infective Endocarditis”. The document contains a “NICE Statement of Endorsement” that the advice supports the implementation of recommendations in GC64. There is no reciprocal endorsement or mention of the SDCEP advice in GC64 and there does not appear to be any such implementation advice applicable to dentists in England and Wales.
• In 2023 the European Society of Cariology (ESC) produced Clinical Practice Guidelines for the management of endocarditis which recommends antibiotic prophylaxis for high risk individuals. The court heard evidence that cardiologists in England and Wales are regularly following this guidance which conflicts with the 2016 NICE guideline.
Responses
Action Planned
NICE has committed to review the current evidence relating to prophylaxis against infective endocarditis this financial year to determine whether any new information supports a further update of existing NICE guidance. (AI summary)
NICE has committed to review the current evidence relating to prophylaxis against infective endocarditis this financial year to determine whether any new information supports a further update of existing NICE guidance. (AI summary)
View full response
Dear Ms Lomas,
I write in response to your regulation 28 report of regarding the very sad death of Mr Michael Briggs. I would like to express my sincere condolences to Mr Briggs’ family.
We have considered the circumstances in your letter regarding dental extraction and the prescribing of antibiotics.
As you have noted in your report, in our guideline on prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures [CG64] we do not routinely recommend antibiotic prophylaxis against infective endocarditis (IE) for people undergoing dental procedures (recommendation 1.1.3).
The recommendation is worded as “do not routinely”, which emphasises NICE's standard advice on healthcare professionals' responsibilities. Doctors and dentists should offer the most appropriate treatment options, in consultation with their patients. In doing so, they should take account of the recommendations in this guideline and the values and preferences of patients, and apply their clinical judgement.
Therefore, if Mr Briggs’ clinical history and circumstances suggested to the dentist that antibiotics might have been appropriate, to prescribe them would have been entirely in line with the discretion supported by the guideline as outlined above.
When we publish our guidelines, we include tools and resources to support implementation. In terms of the Scottish Dental Clinical Effectiveness Programme (SDCEP) implementation advice on antibiotic prophylaxis against infective endocarditis, a link to this endorsed resource is included in the tools and resources section for CG64.
In the 2015 review of CG64, the guideline committee agreed that current evidence was insufficient to support the hypothesis that interventional procedures, including dental extraction, lead to the development of infective endocarditis in people with pre-existing cardiac conditions. Furthermore, the committee concluded that there is insufficient evidence to recommend prophylactic use of antibiotics in those at risk of infective endocarditis undergoing interventional procedures, including dental extraction. From the evidence examined, the committee were unable to establish whether or not prophylaxis was effective.
The issue of conflicting information on the need for antibiotic prophylaxis being provided by cardiologists, dental practitioners and hygienists was raised by the committee as a potential significant problem and the committee discussed the importance of clear and consistent information
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for patients and families and also that a balanced view of the lack of evidence indicating effectiveness of prophylaxis for infective endocarditis as well as any potential harms of prophylaxis should be fully explained to the person considering treatment. This will in turn allow the patient to make an informed decision about continuing/discontinuing prophylaxis.
We have committed to review the current evidence relating to prophylaxis against infective endocarditis this financial year and will determine whether any new information, studies or research would support the case for a further update of existing NICE guidance.
Please do let me know if you require any further information and again, I offer my sincerest condolences to Mr Briggs’ family.
I write in response to your regulation 28 report of regarding the very sad death of Mr Michael Briggs. I would like to express my sincere condolences to Mr Briggs’ family.
We have considered the circumstances in your letter regarding dental extraction and the prescribing of antibiotics.
As you have noted in your report, in our guideline on prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures [CG64] we do not routinely recommend antibiotic prophylaxis against infective endocarditis (IE) for people undergoing dental procedures (recommendation 1.1.3).
The recommendation is worded as “do not routinely”, which emphasises NICE's standard advice on healthcare professionals' responsibilities. Doctors and dentists should offer the most appropriate treatment options, in consultation with their patients. In doing so, they should take account of the recommendations in this guideline and the values and preferences of patients, and apply their clinical judgement.
Therefore, if Mr Briggs’ clinical history and circumstances suggested to the dentist that antibiotics might have been appropriate, to prescribe them would have been entirely in line with the discretion supported by the guideline as outlined above.
When we publish our guidelines, we include tools and resources to support implementation. In terms of the Scottish Dental Clinical Effectiveness Programme (SDCEP) implementation advice on antibiotic prophylaxis against infective endocarditis, a link to this endorsed resource is included in the tools and resources section for CG64.
In the 2015 review of CG64, the guideline committee agreed that current evidence was insufficient to support the hypothesis that interventional procedures, including dental extraction, lead to the development of infective endocarditis in people with pre-existing cardiac conditions. Furthermore, the committee concluded that there is insufficient evidence to recommend prophylactic use of antibiotics in those at risk of infective endocarditis undergoing interventional procedures, including dental extraction. From the evidence examined, the committee were unable to establish whether or not prophylaxis was effective.
The issue of conflicting information on the need for antibiotic prophylaxis being provided by cardiologists, dental practitioners and hygienists was raised by the committee as a potential significant problem and the committee discussed the importance of clear and consistent information
Page | 2
for patients and families and also that a balanced view of the lack of evidence indicating effectiveness of prophylaxis for infective endocarditis as well as any potential harms of prophylaxis should be fully explained to the person considering treatment. This will in turn allow the patient to make an informed decision about continuing/discontinuing prophylaxis.
We have committed to review the current evidence relating to prophylaxis against infective endocarditis this financial year and will determine whether any new information, studies or research would support the case for a further update of existing NICE guidance.
Please do let me know if you require any further information and again, I offer my sincerest condolences to Mr Briggs’ family.
Sent To
- National Institute for Health and Care Excellence
Response Status
Linked responses
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56-Day Deadline
13 Jun 2024
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 13 January 2023 I commenced an investigation into the death of Michael BRIGGS aged
79. The investigation concluded at the end of the inquest on 21 March 2024.
79. The investigation concluded at the end of the inquest on 21 March 2024.
Circumstances of the Death
On 7th November 2022 Michael Briggs consulted with his dentist as to undergoing dental extractions due to pain. He was advised to discuss the safety of such a procedure with his GP as he was taking anticoagulants. On 26th November he returned to his dentist and, having indicated to the dentist that there were no issues with him undergoing the procedure, he proceeded to have three extractions. The procedure was uneventful, and he returned home to recuperate. On 30th November 2022 Mr Briggs was admitted to A & E with a fever and reported a history of bleeding following the extraction. Blood cultures confirmed the presence of staphylococcus aureus and, as Mr Briggs had a bio-prosthetic aortic valve, it was suspected that he had developed infective endocarditis. The diagnosis was confirmed by Trans-oesophageal Echo on 14th December 2022 and he was treated with antibiotics. Despite treatment his condition continued to deteriorate. He was recognised as approaching the end of his life and sadly died at Royal Derby Hospital on 11th January 2023. The court heard evidence that infective endocarditis is a recognised complication of invasive dental procedures for those who have certain underlying health conditions such as valve replacements. For such patients the provision of antibiotic prophylaxis may reduce the risk of developing infective endocarditis. On the evidence before the court, it is not possible to determine whether prophylactic antibiotics would have made a difference to the outcome in Mr Brigg’s case. Narrative conclusion: Michael Briggs died due to recognised complications arising from a dental extraction procedure.
Copies Sent To
DENTIST Royal Derby Hospital
Legal Services
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.