Derek HAND · Prevention of Future Deaths report

On 12 September 2023 I commenced an investigation into the death of Derek HAND aged 93. The investigation concluded at the end of the inquest on 24 April 2024. The conclusion of the inquest was that:

Mr Hand died on 01 September 2023 at Chesterfield Royal Hospital. He was admitted on 26 July 2023 following a tooth extraction on the 25 July 2023, following which he experienced continued bleeding from the extraction site. Mr Hand was on Clopidogrel, an anti-platelet medication, and the tooth extraction was carried out in accordance with the guidance for patients on anti-platelet medication, however the site did not stop bleeding, despite sutures and packing of the site. An ambulance was called at approximately 1am on 26 July, Mr Hand lost consciousness when the ambulance crew was present and was transported to Chesterfield Royal Hospital where he was treated with a blood transfusion and high flow oxygen. His presentation initially improved and discharge was being planned during August. However, Mr Hand developed difficulties swallowing and subsequent aspiration pneumonia. His condition deteriorated at the end of August and he was placed on end of life care before passing away on 01 September 2023.

Attended ED on 26/07/23 with history of tooth extraction earlier in the day, had bleeding, returned to dentist who stitched the area, bleeding stopped at that time, started bleeding again and called ambulance. He had an episode of seizure with ambulance crew that lasted for only a few seconds, self resolved with urinary incontinence. In ED he was given fluid for resuscitation. He had 2 episodes of seizures in ED, became unresponsive in ED after second episode., GCS dropped to 5/15, he was given IV levetiracetam(Keppra).His oxygen saturation was low, started on high flow oxygen, BP dropped to 42 systolic, red cells transfusion started and BP improved to 84/16. He became agitated and confused so he was given midazolam subcut. He continued to deteriorate with hypotension, bradycardia and low GCS so decision was made to start palliative care.
EOL revoked on 28/7/23 due to clinical improvement. Chest Xray showed subtle reticular shadowing in right lower zone. He was treated with IV antibiotic and kept him Nil by mouth. NG tube was inserted on 02/8/23 for nutrition. Started oral trial on 08/08 as per SALT review along with NG feed. NG tube displaced on 10/08, new NG tune re-inserted. MRI brain was done on 16/8/23 to investigate cause for poor swallowing but no acute cause identified. On 30/8/23 Blood Culture showed streptococcus growth and started on Metronidazole in addition to ceftriaxone that he was already on.
He continued to deteriorate so decision was made to proceed with EOL care after discussion with family.

The NHS Education for Scotland Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs states that for patients on Clopidogrel dental treatment can occur without interrupting medication. This is in contrast to, for example, patients on Warfarin, who are required to have an INR test prior to any procedure. Mr Hand's tooth extraction was performed as per the current guidance. As he was on Clopidogrel the procedure was carried out with no further checks being carried out as to his clotting function. Following the tooth extraction the site continued to bleed, to the extent that Mr Hand lost consciousness, required hospital admission and subsequently developed aspiration pneumonia. My concern is that as the current guidance does not require any further checks for patients on Clopidogrel prior to dental procedures there is a risk of other patients on Clopidogrel experiencing excess bleeding following dental procedures. It would be of assistance to know whether:
a. Has any thought been given to requiring an INR test or any other form of blood test to detect a risk of excess bleeding for patients on Clopidogrel prior to dental procedures?
b. If it has not, is there a reason for this?