Patricia Holmes
PFD Report
All Responded
Ref: 2015-0254
All 1 response received
· Deadline: 27 Aug 2015
Coroner's Concerns (AI summary)
The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured ribs and on anticoagulation therapy, leading to inadequate action for their condition.
View full coroner's concerns
The staff grade A&E doctor Who treated Mrs Holmes on February did not consider what action was necessary given the history of trauma and multiple fractured ribs on X-ray and that she was at risk of internal bleeding since she was receiving anticoagulation therapy. The
Responses
Action Taken
East Kent University Hospitals NHS Trust has an approved algorithm in place to assess and treat patients with trauma and bleeding risk. A governor's order was issued at HMP Wayland on June 30, 2015, instructing staff to record medical issues in the wing observation book and the Local Security Strategy has been amended to reflect this procedure. (AI summary)
East Kent University Hospitals NHS Trust has an approved algorithm in place to assess and treat patients with trauma and bleeding risk. A governor's order was issued at HMP Wayland on June 30, 2015, instructing staff to record medical issues in the wing observation book and the Local Security Strategy has been amended to reflect this procedure. (AI summary)
View full response
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Sent To
- East Kent Hospitals University NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
27 Aug 2015
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 12 February 2015 commenced an investigation into the death of Patricia Anne HOLMES. The investigation concluded at the end of the Inquest on 24 June 2015. The conclusion of the inquest was that Accidental,
Circumstances of the Death
Patricia Anne Holmes presented at William Harvey Hospital on February 2015 where a number of fractured ribs were diagnosed on chest x-ray and information was given to the A&E staff by her family that she was receiving anticoagulation therapy for pulmonary embolus and that at the last clinic appointment on 30 January her INR was 6. No action was taken to reverse the effect of the anticoagulation therapy: Mrs Holmes presented again to William Harvey Hospital on 2 February in a state of collapse and died two days later: cause of death is: Ia) Haemothorax 1b) Rib fracture with lung laceration Hypertensive heart disease, Coronary atheroma
Action Should Be Taken
A protocol should be drawn up for the A&E Department to provide for the consideration of reversal of anticoagulation therapy in all cases where a patient has sustained trauma and is in receipt of this type of medication:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.