Concerns raised 6 Failure of the service to provide accessible advice on discontinuing anticoagulants View source Insufficiently robust guidance on maintaining anti-thrombotic medication before dermatological excision View source Failure to obtain advanced consent before dermatological surgery View source Failure to conduct preoperative assessment before dermatological surgery View source Failure to undertake risk-benefit analysis for surgery during anti-thrombotic treatment View source Insufficient guidance on wound-closure technique to achieve haemostasis View source See 3 more concerns
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AI-generated summary
Dr Alan William Kingsbury · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dr Alan William Kingsbury, who was extremely frail, died in hospital on 29 October 2023 after excessive bleeding from a chest lesion excision while taking aspirin and clopidogrel, followed by a fall causing a fractured right neck of femur. The report raised concerns about the robustness of guidance on antithrombotic medication, the absence of preoperative assessment and advanced consent, and the wound-closure technique used to achieve haemostasis.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society For Dermatological Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure of the service to provide accessible advice on discontinuing anticoagulants
Wider context from the report “2. The lack of a Preoperative assessment and advanced consent
Dr Kingsbury was not assessed or consented either in person or by telephone consultation prior to the day of the procedure against current accepted guidelines for surgical procedures. No risk/benefit analysis was undertaken as to the suitability of undertaking the procedure whilst Dr Kingsbury was taking Aspirin and Clopidogrel. Mrs Kingsbury made multiple attempts at communicating with the service without success to obtain advice as to the necessity or otherwise of discontinuing the anticoagulants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society For Dermatological Surgery; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust guidance on maintaining anti-thrombotic medication before dermatological excision
Wider context from the report “1. BSDS (British Society of Dermatological Surgery) Guidelines on Anti-thrombotics and skin surgery for dermatological excisions in the community.
The guidelines as to the suitability of maintaining patients’ anti-thrombotic medication prior to surgical excision are insufficiently robust to reflect bleeding potential from a myriad of factors including the condition of the skin being excised, the position of the lesion and the underlying frailty and medical co-morbidites of individual requiring dermatological surgery in the community. Dr Kingsbury was extremely frail taking Aspirin and Clopidogrel. The lesion to be excised was on the upper chest wall with extremely fragile skin and the excision was larger than expected with some difficulty in obtaining primary closure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society For Dermatological Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain advanced consent before dermatological surgery
Wider context from the report “2. The lack of a Preoperative assessment and advanced consent
Dr Kingsbury was not assessed or consented either in person or by telephone consultation prior to the day of the procedure against current accepted guidelines for surgical procedures. No risk/benefit analysis was undertaken as to the suitability of undertaking the procedure whilst Dr Kingsbury was taking Aspirin and Clopidogrel. Mrs Kingsbury made multiple attempts at communicating with the service without success to obtain advice as to the necessity or otherwise of discontinuing the anticoagulants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society For Dermatological Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct preoperative assessment before dermatological surgery
Wider context from the report “2. The lack of a Preoperative assessment and advanced consent
Dr Kingsbury was not assessed or consented either in person or by telephone consultation prior to the day of the procedure against current accepted guidelines for surgical procedures. No risk/benefit analysis was undertaken as to the suitability of undertaking the procedure whilst Dr Kingsbury was taking Aspirin and Clopidogrel. Mrs Kingsbury made multiple attempts at communicating with the service without success to obtain advice as to the necessity or otherwise of discontinuing the anticoagulants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society For Dermatological Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake risk-benefit analysis for surgery during anti-thrombotic treatment
Wider context from the report “2. The lack of a Preoperative assessment and advanced consent
Dr Kingsbury was not assessed or consented either in person or by telephone consultation prior to the day of the procedure against current accepted guidelines for surgical procedures. No risk/benefit analysis was undertaken as to the suitability of undertaking the procedure whilst Dr Kingsbury was taking Aspirin and Clopidogrel. Mrs Kingsbury made multiple attempts at communicating with the service without success to obtain advice as to the necessity or otherwise of discontinuing the anticoagulants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Society For Dermatological Surgery; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance on wound-closure technique to achieve haemostasis
Wider context from the report “3. Guidance as to the appropriateness of the surgical technique for wound closure
Evidence was heard that due to the fragility of the skin the initial wound closure was not sufficiently deep to effectively achieve haemostasis , requiring closure at a muscular level with different suture technique.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The guidelines are not intended for community surgery, where other guidance may be more appropriate and hospital facilities and expertise differ.
Verbatim wording from the response “5.1 BSDS (British Society of [sic] Dermatological Surgery) Guidelines on Anti-thrombotics and skin surgery for dermatological excisions in the community.” Source location Response from British Society for Dermatological Surgery
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing antithrombotic and skin-surgery guidelines are considered sufficiently robust as drafted, based on clinical expertise and published evidence.
Verbatim wording from the response “Having carefully considered the Coroner’s concerns in the Regulation 28 report, it is the Society’s view that the guidelines referred to are sufficiently robust as currently drafted and based on clinical expertise and published evidence. We hope we have adequately responded to or addressed all your concerns raised in the Regulation 28 report. Thank you for giving us the opportunity to contribute to this investigation.” Source location Response from British Society for Dermatological Surgery
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is no known dermatological surgery evidence that the condition of excised skin affects bleeding risk or should be included in the guideline.
Verbatim wording from the response “The report into the prevention of future deaths states that the BSDS guidance is ‘insufficiently robust to reflect bleeding potential from a myriad of factors including the condition of the skin being excised, the position of the lesion and the underlying frailty and medical co-morbidities…’” Source location Response from British Society for Dermatological Surgery
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations