UK Inquiry Tracker

Vivien Brunning

PFD Report Partially Responded Ref: 2021-0340

Date of Report 12 October 2021

Coroner Graeme Irvine

Coroner Area East London

Response Deadline ✓ from report 7 December 2021

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Critical venous thromboembolism reviews and prescribed daily heparin injections were omitted. Furthermore, a noticed omission was not reported through the Trust's incident system.

View full coroner's concerns

The hospital notes demonstrate that required venous thromboembolism reviews at 24 & 72 hrs following admission were not undertaken: Prescribed daily injections of low molecular weight heparin were omitted on 13th 14th July 2020 The initial omission on 13th July 2020 was noticed by a ward doctor but was not reported through the Trust's incident reporting system.

Responses

Croft Shifa Health Centre Other

23 Feb 2022

Action Taken
The practice held a meeting to discuss patient documentation workflow, agreeing that all DNA and Bardoc visit notifications will be date stamped and forwarded to the addressed GP; the amended policy will be updated by the practice manager and included in staff inductions. (AI summary)

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Dear Ms McKenna With reference to the above and your concerns regarding patient documentation workflow within the practice. We conducted a practice meeting including GP's as well as all administration staff on 20/01/22. Staff were informed regarding the events of the lead up to the passing of Sameena Javed and your concerns regarding the management of patient DNA and Home Visit notifications and how they are currently processed at the practice. The existing records management policy was discussed, and the following changes were agreed: All DNA and Bardoc visit notifications received, whether by normal post/Docman/e-mail, to have date of receipt stamped and scanned if received as paper copy and forwarded to the addressed GP to be reviewed. All documents received via Docman should be work flowed to the addressee, if the GP is on annual or sick leave then the documents should be sent to the GP on-call. All staff were directed that this policy is to be implemented immediately. The amended policy will be updated by the practice manager and replaced in the practice policy folder held in the administration office as well on the practice shared drive folder which is on all computers and to be included in the induction of new staff. We hope that you will be satisfied that we have taken the advised and necessary course of action to ensure that there are no future cases of lapsed patient information and care being forwarded to GPs within our practice.

I apologies that I have not been able to forward the policy to you earlier. I have been away from work caring for my mother and then due to having Covid. Please accept my apologies.

Sent To

Department of Health and Social Care
Queen’s Hospital

Response Status

Linked responses 1 of 2

56-Day Deadline 7 Dec 2021

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 27th July 2020 commenced an investigation into the death of Mrs Vivien Brunning, aged 87 years. The investigation concluded at the end of the inquest on 7ih October 2021_ The conclusion of the inquest was that Mrs Brunning died from; Ia Right Basal Ganglia and Occipital Lobe Ischaemic Strokes 1b Atheromatous thromboembolism during attempted thrombolysis for right brachial artery thrombosis To: Way;

Ic Urosepsis and urinary tract obstruction (treated); systemic atheromatosis, hypercoagulability (omission of clexane therapy) Diabetes Mellitus; atrial fibrillation A short form conclusion of accidental death was arrived at: A narrative conclusion was arrived at:

Circumstances of the Death

On 9th July 2020 Mrs Vivien Brunning was admitted to hospital with sepsis Mrs Brunning had been treated in the community with anti-coagulants for atrial fibrillation. In hospital, a venous thromboembolism ("VTE") assessment indicated that Mrs Brunning required prophylaxis to mitigate the risk of developing deep vein thrombosis as an inpatient; she was prescribed low molecular weight heparin ("Clexane")_ Mrs Brunning was diagnosed with a kidney stone and underwent a nephrostomy to treat the source of her infection. As a precaution, clexane was held, temporarily, to mitigate the risk of bleeding in the procedure_ Following the procedure, clexane was to be resumed and was administered on 12th July 2020. On 13 & 14th July 2020 clexane was not administered to Mrs Brunning, in error: On 15th 2020 Mrs Brunning was diagnosed with a thrombosis in her right brachial artery, a causal factor in the formation of the clot were the two missed doses of clexane. Mrs Brunning underwent an emergency thrombolysis procedure to dissolve the clot; during the procedure she suffered a stroke due to a recognised complication of the essential, emergency procedure Mrs Brunning died on 25th July 2020 due to the effects of the stroke

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action.