Janet Doreen Goodacre · Prevention of Future Deaths report

On 24 May 2013 I commenced an investigation into the death of Janet Doreen Goodacre, age 88. The investigation concluded at the end of the inquest on 10th September 2014.
The cause of death was: 1a Acute Gastrointestinal bleed, 1b. Combination of antiplatelet and anticoagulation therapy, 1c. Atrial Fibrillation and acute coronary syndrome, 2. Myocardial infarction: Congestive cardiac failure.
The conclusion of the inquest was a narrative conclusion :
Mrs Goodacre was admitted to Leicester Royal Infirmary on 1st May 2013 and she remained an in-patient until her death on 21st May 2013. During her stay she developed atrial fibrillation and was started on warfarin, and continued on other medications including deltaparin and aspirin. On the balance of probabilities this combination of medication provoked and then exacerbated a gastro intestinal bleed which led to her death. This was a recognised complication of her necessary medical treatment.

See Narrative Conclusion above

University Hospitals of Leicester NHS Trust (“the Trust”) prepared an Investigation report concerning this death, and this was signed off on 15th January 2014. A copy was duly provided to the Coroner’s office in accordance with the local approved information sharing agreement. On the day of the inquest itself, nearly 9 months later, without any amendments or further communications from the Trust, Evidence was heard that
(1) The Trust acknowledged that the report was factually incorrect

(2) That the only 2 “Root causes” identified in the report were incorrect
(3) the Clinical Lead (who signed off the Investigation Report) said it was “flawed” and “not helpful”

I am therefore concerned that the Trust is providing inaccurate and misleading investigation reports, and Action Plans based on the erroneous findings that are not only of no assistance, but in fact divert attention away from the actual difficulties in service provision that should be identified. This not only fails to achieve the intention of the investigation, but also has the potential to miss opportunities to prevent future deaths. Furthermore, there was a failure to communicate the Trust knowledge of the Investigation Reports shortcomings until the day of the Inquest itself, and it was clear no attempts had been made to revisit the report to correct the recognized errors.

I request to be advised of any actions that have been taken to improve and oversee the preparation and conclusions of Investigation Reports, and that consideration be given to introduce a system to re-open any reports found to be inadequate or erroneous.