Terence William SULLIVAN · Prevention of Future Deaths report

On 16 August 2023 I commenced an investigation and opened an inquest into the death of Terence William SULLIVAN. The investigation concluded at the end of the inquest on 28 February 2024

The conclusion of the inquest was that Mr. Sullivan “Died as the result of complications of necessary surgery, to which the temporary cessation of anticoagulation medication contributed.”

In answer to the questions “when, where and how did Mr. Sullivan come by his death?”, I recorded as follows:

“On 8.8.23 Terence Sullivan underwent a surgical procedure at Worcestershire Royal Hospital to remove a polyp from his sigmoid colon. Mr. Sullivan had been on anticoagulant medication following a previous diagnosis of atrial fibrillation and the insertion of coronary artery stents, and this medication was temporarily suspended so that the procedure on 8.8.23 could go ahead. Following the procedure, Mr. Sullivan suffered an acute myocardial infarction caused by a blockage in a coronary artery stent. Despite treatment, he continued to decline and died in hospital on 10.8.23.”

1) Since June 2023, Mr. Sullivan had been on a single anticoagulant medication ( Rivaroxaban ) to prevent previously inserted coronary stents from blocking. The clinicians who carried out the endoscopic procedure on 8.8.23, however, ensured that he had not taken any Rivaroxaban for the previous 48 hours. This was in accordance with Worcestershire Acute Hospital NHS Trust ( WAHT )’s own guidance, itself based on NICE guidance “NICE Clinical Scenario: Rivaroxaban for a therapeutic endoscopy”. I also heard evidence that the equivalent guidance from the British Society of Gastroenterology ( BSG ) provided similar advice.

At inquest, I heard evidence from WAHT’s Clinical Director for Critical Care that none of the aforementioned guidance considered the specific, and increasingly more common, scenario of a patient with coronary stents who is on a single ( as opposed to more than one ) anticoagulant medication, and who requires a therapeutic endoscopic procedure. The Clinical Director felt that in those specific circumstances, best practice requires pre-operative consultation with an interventional cardiologist, to decide on the best anticoagulation strategy during the procedure.

I am concerned to hear that current guidance on this specific issue from both NICE and BSG may not now reflect current best practice.