Neil Hickman
PFD Report
Partially Responded
Ref: 2022-0064
Coroner's Concerns (AI summary)
Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due to a lack of funding for chelation therapy.
View full coroner's concerns
Mr Hickman was given frequent platelet transfusions at K&C, but his ferritin levels were not measured. When he was referred to UCLH, his ferritin level was found to be hugely raised. He was then treated with chelation therapy and ultimately his ferritin returned to a safe level, so this did not impact upon the outcome. However, it might for another patient.
I think the reason that K&C does not measure the ferritin levels in such a situation is because K&C does not have funding for chelation therapy to treat iron overload. However, if iron overload is detected, then a referral centre such as UCLH can be called for advice, and the patient and their family can be informed so that they have the option of seeking private treatment.
I think the reason that K&C does not measure the ferritin levels in such a situation is because K&C does not have funding for chelation therapy to treat iron overload. However, if iron overload is detected, then a referral centre such as UCLH can be called for advice, and the patient and their family can be informed so that they have the option of seeking private treatment.
Responses
Action Taken
The hospital has implemented a policy that all Myelodysplastic Syndrome patients undergoing frequent red cell transfusions and being referred for a bone marrow transplant will have their ferritin levels measured. (AI summary)
The hospital has implemented a policy that all Myelodysplastic Syndrome patients undergoing frequent red cell transfusions and being referred for a bone marrow transplant will have their ferritin levels measured. (AI summary)
View full response
Dear Madam
Mr Neil Hickman – PFD Response
Thank you for your Prevention of Future Death (PFD) Report dated 28 February 2022 sent pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 concerning the death of Mr Neil Hickman on 21 August 2021.
I understand that during the course of the inquest you heard evidence that revealed matters giving a rise to a concern that needs to be addressed to prevent a future death. Specifically, you are concerned that when Mr Hickman was referred for a bone marrow transplant, his ferritin levels were not checked despite him undergoing frequent blood transfusions.
Your PFD Report was discussed in the Haematology Departmental business meeting on 10 March
2022. It has now been agreed that all Myelodysplastic Syndrome patients that are undergoing frequent red cell transfusions and being referred for a bone marrow transplant will have their ferritin levels measured. This will ensure that if iron overload is detected, appropriate measures can be initiated including referral to a specialist centre for urgent treatment. This action has been implemented with immediate effect.
Lastly, I would like to thank you for bringing your concern to our attention and can assure you and Mr Hickman’s family that the Trust will continue to improve on the high standards we set ourselves in East Kent Hospitals.
Mr Neil Hickman – PFD Response
Thank you for your Prevention of Future Death (PFD) Report dated 28 February 2022 sent pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 concerning the death of Mr Neil Hickman on 21 August 2021.
I understand that during the course of the inquest you heard evidence that revealed matters giving a rise to a concern that needs to be addressed to prevent a future death. Specifically, you are concerned that when Mr Hickman was referred for a bone marrow transplant, his ferritin levels were not checked despite him undergoing frequent blood transfusions.
Your PFD Report was discussed in the Haematology Departmental business meeting on 10 March
2022. It has now been agreed that all Myelodysplastic Syndrome patients that are undergoing frequent red cell transfusions and being referred for a bone marrow transplant will have their ferritin levels measured. This will ensure that if iron overload is detected, appropriate measures can be initiated including referral to a specialist centre for urgent treatment. This action has been implemented with immediate effect.
Lastly, I would like to thank you for bringing your concern to our attention and can assure you and Mr Hickman’s family that the Trust will continue to improve on the high standards we set ourselves in East Kent Hospitals.
Sent To
- East Kent Hospitals University NHS Foundation Trust ›Medical
- Kent and Canterbury Hospital
Response Status
Linked responses
1 of 2
56-Day Deadline
25 Apr 2022
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 25 August 2021, one of my assistant coroners, Sarah Bourke, commenced an investigation into the death of Neil Hickman aged 63 years. The investigation concluded at the end of the inquest earlier today. I made a determination at inquest of death by natural causes.
Circumstances of the Death
Neil Hickman was treated at Kent and Canterbury Hospital (K&C) for myelodysplastic syndrome and then was referred to University College London Hospital (UCLH) for stem cell transplant. However, he died before the transplant could take place. His medical cause of death was: 1a disseminated angio-invasive mycotic infection 1b immunosuppression 1c myelodysplasia
Copies Sent To
University College London Hospitals NHS Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.