Jack Hurn
8 Jun 2022 · Coroner Emma Brown · Birmingham and Solihull
The coroner's concerns
1. lack of official guidance on managing VITT
“There was no official national guidance and no approved Trust guidance on managing VITT in place at the time this patient was admitted to AGH, therefore staff are unlikely to have been aware of the time- critical need to transfer the patient to a specialist centre (QEHB)”
2. continued medical management instead of referral to specialist team
“The Neurosurgical team at QEHB advised to continue medical management locally (at WAHT).”
3. incorrect referral to neurosurgery instead of haematology and neurology
“The Neurosurgical team at QEHB were contacted for advice; had the Trust VITT guidance been in place at the time, it would have stipulated not to contact the Neurosurgical team, but instead to contact Haematology and Neurology at QEHB.”
4. insufficient investigation failing to safeguard patients
“the investigation was not sufficient and as such has not served its purpose of safeguarding patients.”
5. lack of explanation for incomplete investigation
“No adequate explanation was given in evidence to explain why the investigation was incomplete.”
6. inadequate investigations leading to unlearned lessons
“If WAH serious incident investigations are not sufficient the lessons arising will not be identified and necessary action will not be taken putting lives at risk.”
Responses
2022-0167-Response-from-NHS-Worcestershire-Acute-Hospital.pdf ↗· Worcestershire Acute Hospitals NHS Trust
Stated action · 7th October
“system for reporting and monitoring of serious incidents across England) and the revised terms of reference for the investigation to include the issues that you have identified. The revised report is now being reviewed independently of the clinical division responsible for the care delivery, by my Deputy Chief Medical Officer, and will be shared with [the deceased]'s family and with our Integrated Care Board by 7th October”