PFD report

Patricia Anne HOLMES · Prevention of Future Deaths report

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Issued 2 Jul 2015•Central and South East Kent

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised1

  1. Failure to consider necessary action in light of trauma, multiple fractured ribs and anticoagulation-related internal bleeding risk
    Part of recurring concern: Inadequate controls for bleeding risk in patients taking antithrombotic medication
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Implement the approved Chest Trauma Algorithm across the Trust’s emergency departments to guide triage, assessment, treatment, anticoagulation reversal and haematology advice.

    Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 July 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Existing mitigation focuses on chest injuries rather than extending the response to all trauma-related injuries.

    Stated by East Kent Hospitals University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to consider necessary action in light of trauma, multiple fractured ribs and anticoagulation-related internal bleeding risk

Wider context from the report

“The staff grade A&E doctor who treated Mrs Holmes on 1 February did not consider what action was necessary given the history of trauma and multiple fractured ribs on x-ray and that she was at risk of internal bleeding since she was receiving anticoagulation therapy. ”

Is this part of a recurring concern?

Yes — Inadequate controls for bleeding risk in patients taking antithrombotic medication.

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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 the approved Chest Trauma Algorithm across the Trust’s emergency departments to guide triage, assessment, treatment, anticoagulation reversal and haematology advice.

Verbatim wording from the response

“Prior to the inquest being resumed, the Trust had already disclosed to you a draft Chest Trauma Algorithm and this has been approved and is now in place throughout the emergency departments of the Trust. The aim of the Algorithm is to safely triage, assess and treat patients who present with chest trauma. It has been designed to consider the reversal of anticoagulation, Box 1, of the Algorithm specifically directs the reader to consider the reversal of anticoagulation and to seek expert advice from the Trust's haematologists upon advice from the haematology committee on treatment within the Algorithm.”

Source location

2015-0254-Response-by-East-Kent-University-Hospitals-NHS-Trust
Page 1 · response
Published 2 July 2015

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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

Existing mitigation focuses on chest injuries rather than extending the response to all trauma-related injuries.

Verbatim wording from the response

“Mrs Holmes' case related to a chest trauma and the effects of the anticoagulant medication (Acenocoumarol) with her injuries. The Emergency Department and Surgical staff have therefore looked at mitigating similar events for future patients who present with chest injuries rather than all trauma-related injuries.”

Source location

2015-0254-Response-by-East-Kent-University-Hospitals-NHS-Trust
Page 1 · response
Published 2 July 2015

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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

An existing trauma protocol is considered more appropriate than a medication-specific anticoagulation pathway.

Verbatim wording from the response

“Within your Regulation 28 Report dated 29 June 2015 you recommended that the Trust should have a protocol in place for the use of an anticoagulation pathway in all cases where a patient has sustained trauma and is in receipt of this type of medication. In view of the importance of maintaining clinical trauma and in respect of this type of medication, the Trust has a protocol which is used to assist and guide the management of patients with trauma. This is more appropriate than a protocol related to a specific type of medication.”

Source location

2015-0254-Response-by-East-Kent-University-Hospitals-NHS-Trust
Page 1 · response
Published 2 July 2015

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026