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
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Implement documented preoperative assessments to identify risks of complications from skin surgery.
View source
Action
Provide advanced consent and schedule procedures to allow appropriate adjustment of anticoagulation.
View source
Action
Integrate any amended British Society of Dermatological Surgery guidance on anticoagulants into service policy.
View source
Action
Close surgical excision wounds with deep self-dissolving subcutaneous sutures and cutaneous sutures.
View source
Action
Highlight to clinicians the importance of adequate deep wound closure for patients at higher risk of postoperative bleeding or wound dehiscence.
View source See 2 more actions
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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 Sussex Community Dermatology Service; 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 Sussex Community Dermatology Service; 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 Sussex Community Dermatology Service; 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 Sussex Community Dermatology Service; 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 Sussex Community Dermatology Service; 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 Sussex Community Dermatology Service; 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 action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement documented preoperative assessments to identify risks of complications from skin surgery.
Verbatim wording from the response “▪ Action to be taken:
SCDS will ensure that its policies are sufficiently robust to be able to identify at risk patients at the time of 1st encounter and ensure that risk mitigation measures are in place. To achieve this, we will do the following:
- Perform a thorough documented preoperative assessment to assess risk of complications associated with skin surgery.
- Ensure advanced consent and scheduling of the procedure to allow adjustment of anticoagulation as appropriate.” Source location Response from Surrey Community Dermatology Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide advanced consent and schedule procedures to allow appropriate adjustment of anticoagulation.
Verbatim wording from the response “▪ Action to be taken:
SCDS will ensure that its policies are sufficiently robust to be able to identify at risk patients at the time of 1st encounter and ensure that risk mitigation measures are in place. To achieve this, we will do the following:
- Perform a thorough documented preoperative assessment to assess risk of complications associated with skin surgery.
- Ensure advanced consent and scheduling of the procedure to allow adjustment of anticoagulation as appropriate.” Source location Response from Surrey Community Dermatology Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrate any amended British Society of Dermatological Surgery guidance on anticoagulants into service policy.
Verbatim wording from the response “- Follow up-to-date guidance regarding anticoagulants in skin surgery.
- Always ensuring a favourable risk: benefit profile” Source location Response from Surrey Community Dermatology Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Close surgical excision wounds with deep self-dissolving subcutaneous sutures and cutaneous sutures.
Verbatim wording from the response “• Our clinicians are all very experienced in skin surgery and we routinely monitor various aspects of their practice including postoperative infections, postoperative bleeding and wound dehiscence as part of our ongoing clinical governance using RADAR software. Our complication rates are very low and comparable to all our local NHS trust services. Surgical excision wounds are routinely closed with a deep layer of self-dissolving subcutaneous sutures and cutaneous sutures.” Source location Response from Surrey Community Dermatology Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highlight to clinicians the importance of adequate deep wound closure for patients at higher risk of postoperative bleeding or wound dehiscence.
Verbatim wording from the response “▪ Action to be taken:
We will use this case to highlight the importance of ensuring adequate deep closure of wounds especially when dealing with patients at higher risk of postoperative bleeding and wound dehiscence.” Source location Response from Surrey Community Dermatology Service
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 Responsibility for responding to the concern about BSDS guidance rests with BSDS; SCDS will await any revised guidance.
Verbatim wording from the response “• This concern has been addressed directly to the BSDS so SCDS will not comment on this but await the response from the BSDS and any change to the current guidance” Source location Response from Surrey Community Dermatology Service
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