Michael Drewell
PFD Report
All Responded
Ref: 2018-0259
All 1 response received
· Deadline: 21 Nov 2018
Coroner's Concerns (AI summary)
A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic notes, highlighting a dangerous reliance on digital records over handwritten instructions.
View full coroner's concerns
_ The treating Consultant advised that Mr Drewell; because of his height and weight;, be given the anti-coagulant Tinzaparin for six weeks rather than four weeks a8 was usual. He recorded his advice on the handwritten records at hospital following a ward round the after surgery_ When the Junior Doctor came to prescribe Tinzaparin several days later he likely did not consult the handwritten notes and only prescribed four weeks Tinzaparin immediately before Mr Drewell's discharge from hospital. Evidence was heard that Junior Doctors would not be expected to consult the handwritten notes when prescribing drugs in accordance with NICE Guidelines. It Is of concern that the advice of a Senior Clinician was not followed and, further; that his advice was not placed upon the electronic notes.
Responses
Action Planned
Leeds Teaching Hospitals NHS Trust will remind clinicians about the importance of robust handover and communication. They will also ensure individual clinicians prescribing 'off protocol' either action this themselves personally or leave clear unambiguous instructions within the electronic record. (AI summary)
Leeds Teaching Hospitals NHS Trust will remind clinicians about the importance of robust handover and communication. They will also ensure individual clinicians prescribing 'off protocol' either action this themselves personally or leave clear unambiguous instructions within the electronic record. (AI summary)
View full response
Dear Sir 4( 73 knlcflu (Ja
22. &( P Inqueet touching death of Mlchael John DREWELL refer to your correspondence of 30th August 2018, received on 31st Auguet regarding the inquest touching the death of Michael John Drewell and the Regulation 28 Report fo Prevent Future Deaths in respect of this case. Your letter has been forwarded on for me a8 Chlef Medical Officer for the Trust to respond to. can confimm that the contents of your Regulation 28 Report have been shared with relevant staff t0 enable us to provide you with a comprehensive response. In your report you highlight that your matters of concern are: (1) The treating consultant advised that Mr Drewell; because of his height and weight; be given the anticoagulant Tinzaparin for six weeke rather than four weeks 88 was usual. He recorded his advice on the handwritten records at hospital following a ward round the day after surgery: When the junior doctor came to prescribe Tinzaparin several later he did not consult the handwritten notes and only prescribed four weeks Tlnzaparin Immedlately before Mr Drewelfs dlscharge hospital; (2) The advice of a senior clinician was not followed and, further; that his advice was not placed upon the ekctronic noteg_ The team has considered the contents of your correspondence carefully and the responses to the matters of concer you have ralsed in the report are detailed below. The clinical team have advised me that Mr Drewell was a 57-year-old gentleman who fell his bicycle whilst travelling to work on 16th November 2017. He attended Leeds General Infirmary and was diagnosed with & displaced fracture of his right hip On the day following surgery, the orthopaedic consultant advised thatMl Chair Dr LInda Pollard €BE DL Hon DLL Chief Executive Julian Hartley The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospltal Leeds Dental Institute Seacoft Hospital Leeds Chidren$ Hospital St Jaines} University Hospltal Leeds General Infirinary Wharfedale Hospital Leeds Cancer Centre WIZ5 201 the the days from very from the us0 Number NHS
Drewell take Tinzaparin for six Weeks to reduce the risk of deep vein thrombosis, He wa8 discharged on 22nd November and was provided instead with a four week course of Tinzaparin; & prescription given in accordance with NICE guidance On 22nd December 2017 Mr Drewell suffered a cardiac anest at home and paramedics were unable to resuscitate him: He was pronounced dead at 23.55 that day: A post-mortem examination revealed that Mr Drewell had suffered & pulmonary embolism: The course of Tinzaparin had stopped two prior to Mr Drewell's collapse At the inquest It wag accepted that it was not possible to say that the ending of the prescription more than minimally contributed t0 his death. The Trust provided a root cause analysis summary that concluded that the correct dose of Tinzaparin had been prescribed for & gentleman of Mr Drewelle height and weight and that there had been no Japses in care. Tinzaparin was prescribed at discharge according to NICE guidance: The trust has therefore determined that; notwithstanding request by an indivdual consultant; Tinzaparin was correctly prescribed for Mr Drewell and it is not possible to gay that a longer course of the anticoagulant would have prevented his death_ In your Regulation 28 Report you highlight the fact Ihat the junior doctor did not consult the hand-written medical records before prescribing the discharge medication: am sure that you wll agree that it is impractical for junior doctors to comprehensively review the medical record in its entirety when completing the electronic discharge advice note (EDAN) and prescription; It is therefore Imperative that if individual clinicians decide to prescriba 'off protocol' they either action this themselves personally; or leave clear unambiguous Instructions within the electronic record: This can be done In two ways; either the eMeds electronic prescrbing chart can be annotated or the EDAN can be pre-populated with specific discharge advice It is regrettabke that neither of these were done on this occasion and written to the Clinical Directors and asked that remind all clinicians about the importance of robust handover and communication. can reassure you that good practice Is already embedded within many clinical ereas throughout the Trust: For example, Elderly Medicine patients with pelvic fractures who are belng discharged to care in the community (CIC) beds have Tinzaparin continued until are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this infomation is then pulled through automatically to the EDAN: In addition, our phammaciete will also add electronic notes regarding discharge medication advlce following multi-disciplinary team meetings with treating clinicians: Thank you for bringing these matters to my attention. do that thia response has assured you that the Trust has given careful consideration to the matters of days the have they they : hope
The Leeds Teaching Hospitals [7E concern you have raised: If I can be of any further assistance pleaNHSdbthesitate t0 contact me Kind regards:
22. &( P Inqueet touching death of Mlchael John DREWELL refer to your correspondence of 30th August 2018, received on 31st Auguet regarding the inquest touching the death of Michael John Drewell and the Regulation 28 Report fo Prevent Future Deaths in respect of this case. Your letter has been forwarded on for me a8 Chlef Medical Officer for the Trust to respond to. can confimm that the contents of your Regulation 28 Report have been shared with relevant staff t0 enable us to provide you with a comprehensive response. In your report you highlight that your matters of concern are: (1) The treating consultant advised that Mr Drewell; because of his height and weight; be given the anticoagulant Tinzaparin for six weeke rather than four weeks 88 was usual. He recorded his advice on the handwritten records at hospital following a ward round the day after surgery: When the junior doctor came to prescribe Tinzaparin several later he did not consult the handwritten notes and only prescribed four weeks Tlnzaparin Immedlately before Mr Drewelfs dlscharge hospital; (2) The advice of a senior clinician was not followed and, further; that his advice was not placed upon the ekctronic noteg_ The team has considered the contents of your correspondence carefully and the responses to the matters of concer you have ralsed in the report are detailed below. The clinical team have advised me that Mr Drewell was a 57-year-old gentleman who fell his bicycle whilst travelling to work on 16th November 2017. He attended Leeds General Infirmary and was diagnosed with & displaced fracture of his right hip On the day following surgery, the orthopaedic consultant advised thatMl Chair Dr LInda Pollard €BE DL Hon DLL Chief Executive Julian Hartley The Leeds Teaching Hospitals incorporating: Chapel Allerton Hospltal Leeds Dental Institute Seacoft Hospital Leeds Chidren$ Hospital St Jaines} University Hospltal Leeds General Infirinary Wharfedale Hospital Leeds Cancer Centre WIZ5 201 the the days from very from the us0 Number NHS
Drewell take Tinzaparin for six Weeks to reduce the risk of deep vein thrombosis, He wa8 discharged on 22nd November and was provided instead with a four week course of Tinzaparin; & prescription given in accordance with NICE guidance On 22nd December 2017 Mr Drewell suffered a cardiac anest at home and paramedics were unable to resuscitate him: He was pronounced dead at 23.55 that day: A post-mortem examination revealed that Mr Drewell had suffered & pulmonary embolism: The course of Tinzaparin had stopped two prior to Mr Drewell's collapse At the inquest It wag accepted that it was not possible to say that the ending of the prescription more than minimally contributed t0 his death. The Trust provided a root cause analysis summary that concluded that the correct dose of Tinzaparin had been prescribed for & gentleman of Mr Drewelle height and weight and that there had been no Japses in care. Tinzaparin was prescribed at discharge according to NICE guidance: The trust has therefore determined that; notwithstanding request by an indivdual consultant; Tinzaparin was correctly prescribed for Mr Drewell and it is not possible to gay that a longer course of the anticoagulant would have prevented his death_ In your Regulation 28 Report you highlight the fact Ihat the junior doctor did not consult the hand-written medical records before prescribing the discharge medication: am sure that you wll agree that it is impractical for junior doctors to comprehensively review the medical record in its entirety when completing the electronic discharge advice note (EDAN) and prescription; It is therefore Imperative that if individual clinicians decide to prescriba 'off protocol' they either action this themselves personally; or leave clear unambiguous Instructions within the electronic record: This can be done In two ways; either the eMeds electronic prescrbing chart can be annotated or the EDAN can be pre-populated with specific discharge advice It is regrettabke that neither of these were done on this occasion and written to the Clinical Directors and asked that remind all clinicians about the importance of robust handover and communication. can reassure you that good practice Is already embedded within many clinical ereas throughout the Trust: For example, Elderly Medicine patients with pelvic fractures who are belng discharged to care in the community (CIC) beds have Tinzaparin continued until are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this infomation is then pulled through automatically to the EDAN: In addition, our phammaciete will also add electronic notes regarding discharge medication advlce following multi-disciplinary team meetings with treating clinicians: Thank you for bringing these matters to my attention. do that thia response has assured you that the Trust has given careful consideration to the matters of days the have they they : hope
The Leeds Teaching Hospitals [7E concern you have raised: If I can be of any further assistance pleaNHSdbthesitate t0 contact me Kind regards:
Sent To
- Leeds Teaching Hospitals NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
21 Nov 2018
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 3r January 2018 | commenced an investigation into death of Michael John Drewell, aged 57_ The investigation concluded at the end of the inquest on 22n August 2018. The conclusion of the inquest was that Mr Drewell died of a pulmonary thromboembolism ,
Circumstances of the Death
On the 16th November 2017 Mr Drewell fell of his bike whilst travelling to work He attended at Leeds General Infirmary and was diagnosed with a displaced uitra capsular fracture of his right hip. He subsequently underwent surgery and his fracture was fixed with cannulated screws_ On the 17/h November 2017 his treating Consultant advised that he take Tinzaparin for six weeks to reduce the risk of Deep Vein Thrombosis . He was discharged from hospital on the 22nd November 2017 and was provided with a four week prescription for Tinzaparin: That prescription was given in accordance with National Guidelines but was not for the period of time; (ie six weeks), as advised by the Consultant The prescription ended two prior to his death It is not possible to say whether the ending of the prescription more than minimally contributed to his death On the 22" December 2017 he suffered a cardiac arrest at home. Paramedics attended but were unable to resuscitate him: He was then taken to the Leeds General Infirmary and death was pronounced at 2355 hours that He died of a pulmonary thromboembolism which was a complication of his earlier hip surgery: the hip days day: likely
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;
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.