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The role of HM Coroners in promoting patient safety

The important work of Coroners in promoting patient safety can be illustrated by two recent Prevention of Future Death (‘PFD’) reports. These reports are made by Coroners who hear evidence during an inquest which raises issues of concern, and where it is believed an individual or organisation/s can take steps to prevent future similar incidents.

When 68 year old Robert Goodman fell in Southampton General Hospital and sustained a head injury he was not offered a brain scan until 30 hours later, when a bleed on the brain was diagnosed. The hospital guidelines and policies mandated a scan within 8 hours for patients on anticoagulants, but he was on enoxaparin – a type of anticoagulant known as a novel oral anticoagulant (‘NOAC’) a relatively new and effective alternative to warfarin – and this was deemed to be a ‘low dose anticoagulant’ and therefore there was thought to be no need to check for bleeding with a scan.

At an inquest into his death the Coroner found that the hospital guidelines did not take into account updated guidance from the National Institute for Health and Social care excellence indicating that patients that are on any anticoagulants should have a CT scan within 8 hours of head injury.

First do no harm

When 91 year old Stanley Babbs was referred for a CT scan to rule out a possible malignancy he was given intravenous contrast, despite his history of chronic kidney disease and other co-morbidities. He suffered a contrast induced kidney injury and was admitted to hospital, where he died of sepsis.

The Coroner found that, whilst there was a Practice Group Direction for the administration of contrast (which is a prescription only medicine) to those who were not at risk of acute kidney injury, there was no such Practice Group Direction for those at higher risk, and that contrast was routinely given without a formal prescription or evidence of a careful consideration of the dose.

Trusts which are issued a PDF report are under an obligation to respond to the report within a stipulated time, containing details of any action taken or a timetable for any proposed action, or an explanation why no action is proposed.