PFD report

Michael John Drewell · Prevention of Future Deaths report

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Issued 30 Aug 2018•West Yorkshire Eastern

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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to follow senior clinician anticoagulant-duration advice
    Part of recurring concern: Unreliable doctor-to-doctor coordination of prescribingPart of recurring concern: Unsafe medication prescribing
  2. Failure to record senior clinician advice in electronic notes
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionablePart of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable recording and confirmation of specialist clinical advice
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.2

  1. Action

    Record post-discharge Tinzaparin instructions on electronic drug charts and transfer them automatically to electronic discharge advice notes for eligible patients.

    Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
  2. Action

    Add electronic notes recording discharge medication advice after multidisciplinary team meetings with treating clinicians.

    Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.

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

  1. Position

    Comprehensively reviewing the entire medical record before electronic discharge prescribing is considered impractical for junior doctors.

    Stated by Leeds Teaching Hospitals NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 follow senior clinician anticoagulant-duration advice

Wider context from the report

“The treating Consultant advised that Mr Drewell, because of his height and weight, be given anti-coagulant Tinzaparin for six weeks rather than four weeks as was usual. He recorded his advice on the handwritten records at hospital following a ward round the day after surgery. When the Junior Doctor came to prescribe Tinzaparin several days later he likely did not consult the handwritten notes and only prescribed four weeks Tinzaparin immediately before Mr Drewell’s discharge from hospital. Evidence was heard that Junior Doctors would not be expected to consult the handwritten notes when prescribing drugs in accordance with NICE Guidelines. It is of concern that the advice of a Senior Clinician was not followed and, further, that his advice was not placed upon the electronic notes. ”

Is this part of a recurring concern?

Yes — Unreliable doctor-to-doctor coordination of prescribing; Unsafe medication prescribing.

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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 record senior clinician advice in electronic notes

Wider context from the report

“The treating Consultant advised that Mr Drewell, because of his height and weight, be given anti-coagulant Tinzaparin for six weeks rather than four weeks as was usual. He recorded his advice on the handwritten records at hospital following a ward round the day after surgery. When the Junior Doctor came to prescribe Tinzaparin several days later he likely did not consult the handwritten notes and only prescribed four weeks Tinzaparin immediately before Mr Drewell’s discharge from hospital. Evidence was heard that Junior Doctors would not be expected to consult the handwritten notes when prescribing drugs in accordance with NICE Guidelines. It is of concern that the advice of a Senior Clinician was not followed and, further, that his advice was not placed upon the electronic notes. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable; Incomplete, inaccurate or unavailable clinical and care records; Unreliable recording and confirmation of specialist clinical advice.

Open source report

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

Record post-discharge Tinzaparin instructions on electronic drug charts and transfer them automatically to electronic discharge advice notes for eligible patients.

Verbatim wording from the response

“I can reassure you that good practice is already embedded within many clinical areas throughout the Trust. For example, Elderly Medicine patients with pelvic fractures who are being discharged to care in the community (CIC) beds have Tinzaparin continued until they are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this information is then pulled through automatically to the EDAN. In addition, our pharmacists will also add electronic notes regarding discharge medication advice following multi-disciplinary team meetings with treating clinicians.”

Source location

2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 26 September 2018

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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

Add electronic notes recording discharge medication advice after multidisciplinary team meetings with treating clinicians.

Verbatim wording from the response

“I can reassure you that good practice is already embedded within many clinical areas throughout the Trust. For example, Elderly Medicine patients with pelvic fractures who are being discharged to care in the community (CIC) beds have Tinzaparin continued until they are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this information is then pulled through automatically to the EDAN. In addition, our pharmacists will also add electronic notes regarding discharge medication advice following multi-disciplinary team meetings with treating clinicians.”

Source location

2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 26 September 2018

Open published response

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

Comprehensively reviewing the entire medical record before electronic discharge prescribing is considered impractical for junior doctors.

Verbatim wording from the response

“In your Regulation 28 Report you highlight the fact that the junior doctor did not consult the hand-written medical records before prescribing the anticoagulant medication. I am sure that you will agree that it is impractical for junior doctors to comprehensively review the medical record in its entirety when completing the electronic discharge advice note (EDAN) and prescription. It is therefore imperative that if individual clinicians decide to prescribe ‘off protocol’ they either action this themselves personally, or leave clear unambiguous instructions within the electronic record. This can be done in two ways; either the eMeds electronic prescribing chart can be annotated or the EDAN can be pre-populated with specific discharge advice.”

Source location

2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 26 September 2018

Open published response

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 Trust determined that Tinzaparin was correctly prescribed under NICE guidance, and a longer course could not be shown to have prevented death.

Verbatim wording from the response

“At the inquest it was accepted that it was not possible to say that the ending of the prescription more than minimally contributed to his death. The Trust provided a root cause analysis summary that concluded that the correct dose of Tinzaparin had been prescribed for a gentleman of Mr Drewell’s height and weight and that there had been no lapses in care. Tinzaparin was prescribed at discharge according to NICE guidance. The trust has therefore determined that, notwithstanding the request by an individual consultant, Tinzaparin was correctly prescribed for Mr Drewell and it is not possible to say that a longer course of the anticoagulant would have prevented his death.”

Source location

2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 26 September 2018

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Write to Clinical Directors requesting reminders to clinicians about robust handover and communication.

    Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.

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

Write to Clinical Directors requesting reminders to clinicians about robust handover and communication.

Verbatim wording from the response

“It is regrettable that neither of these were done on this occasion and I have written to the Clinical Directors and asked that they remind all clinicians about the importance of robust handover and communication.”

Source location

2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 26 September 2018

Open published response
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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