Margaret Hions
PFD Report
All Responded
Ref: 2016-0047
All 1 response received
· Deadline: 8 Apr 2016
Coroner's Concerns (AI summary)
Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.
View full coroner's concerns
The MATTERS OF CONCERN is as follows:
(1) That there should be a review of the current Health Board practice in the prescribing of tinzaparin medication and the monitoring of blood levels.
(2) That the importance of monitoring creatinine clearance as per Health Board clinical pharmacy policy to be reiterated to medical team and pharmacists. These matters were identified by a Root Cause Analysis Investigation report but it was unclear at the inquest whether these recommendations have yet been acted upon. 2
(1) That there should be a review of the current Health Board practice in the prescribing of tinzaparin medication and the monitoring of blood levels.
(2) That the importance of monitoring creatinine clearance as per Health Board clinical pharmacy policy to be reiterated to medical team and pharmacists. These matters were identified by a Root Cause Analysis Investigation report but it was unclear at the inquest whether these recommendations have yet been acted upon. 2
Responses
Action Planned
The Health Board has reviewed its practice in the prescribing of tinzaparin and monitoring of blood levels, and a revised guideline has been produced, subject to consultation and approval; the importance of monitoring creatinine clearance is being reiterated to clinicians and pharmacists. (AI summary)
The Health Board has reviewed its practice in the prescribing of tinzaparin and monitoring of blood levels, and a revised guideline has been produced, subject to consultation and approval; the importance of monitoring creatinine clearance is being reiterated to clinicians and pharmacists. (AI summary)
View full response
Dear Mr Layton Inquest touching the death of Mrs Margaret Hions Thank you for you correspondence, enclosing the Regulation 28 report; following the inquest of Mrs Hions_ I apologise for the shortcomings in her care that were identified as part of the inquest and investigation into Mrs Hions death namely the prescribing of Tinzaparin and the monitoring of creatinine in accordance with Health Board policy In relation to recommendation to review Health Board practice in the prescribing of tinzaparin medication and monitoring of blood levels, I can confirm that this has been reviewed and a revised guideline for prescribing and monitoring low molecular weight heparin had been produced_ This is currently subject to consultation within the Health Board and will be presented to the next scheduled meetings of both the Medicines Management Group and Clinical Policy Review Group for approval: importance of monitoring creatinine clearance is being reiterated by letter from the Medical Director to all clinicians and clinical pharmacists; this will also be included in the Medicines Management Group newsletter which is widely circulated and by global e-mail to all staff, upon approval of the above guideline. Swyddteydd Corforaethol, Adeilad Ystwyth, Corporate Offices Ystwylh Buildirig Cadeirycd Cnair Hafan Derwven, Parc Dewi Sant; Hecl Ffynnon Jod. Hafan Derwen, St Davids Park, Job'$ Well Road , Mrs Bernardine Rees OBE Caerfyrcdin, Sir Gaorfyrddir, S431 3BB Camarthen_ Carmarlnershire; S431 3BB Prif WelthredwiIChief Executive Mr Steve Moore the The
If you require further information, please do not hesitate to contact me or Louise OConnor, Assistant Director (Patient Experience) on the above contact numberle-mail:
If you require further information, please do not hesitate to contact me or Louise OConnor, Assistant Director (Patient Experience) on the above contact numberle-mail:
Sent To
- West Wales General Hospital
Response Status
Linked responses
1 of 1
56-Day Deadline
8 Apr 2016
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 3rd September 2013 I commenced an investigation into the death of Margaret Hions . The investigation concluded at the end of the inquest on 12th February 2016. The conclusion of the inquest was a narrative conclusion namely that: Margaret Hions died on 27th August 2013 from pulmonary infarction and coronary artery atherosclerosis in an elderly woman who had sustained breakdown of a left gluteal haematoma caused by tinzaparin therapy. There were shortcomings in the management of her care at Glangwili Hospital.
Circumstances of the Death
(1) Mrs Hions was admitted to Glangwili Hospital on 1 July 2013 with increasing shortness of breath, decreased mobility, loss of appetite, nausea and vomiting. At the time of her admission she was prescribed warfarin. A decision was made to replace warfarin with tinzaparin. (2) Mrs Hions remained in hospital and during her admission a large bruise was observed which expanded rapidly. (3) As a result of this the tinzaparin was stopped. (4) Mrs Hions was subsequently transferred to the Prince Philip Hospital where she passed away on 27th August 2013.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.