Christopher COLLINSON · Prevention of Future Deaths report

On 24 June 2021, I commenced an investigation into the death of Christopher COLLINSON. The investigation concluded at the end of the inquest on 26th October 2021. The conclusion of the inquest was; Natural causes

Christopher Collinson was admitted to MAU at Birmingham Heartlands Hospital on 14th June 2021 with suspected DVT and PE. He arrived at the hospital at 13.28, however was not clerked by a Doctor until 21.33. The reason given for this was that the department was highly pressured on this date, and although a Junior Doctor had assigned the case to them by "clicking", that Doctor had not in fact been able to see Mr Collinson. He did not "unclick" the patient and therefore other Doctors who may have had capacity were not aware that Mr Collinson had not been seen.

When Mr Collinson was seen by a Doctor, the Doctor prescribed a prophylactic dose of Enoxaparin rather than the therapeutic dose which she had intended to prescribe. The reason for this was that the electronic prescribing system is a drop down box with confusing tables to select the medication. The Doctor was under pressure due to the busy department and accepted this was human error, having accidently selected the wrong one. I was also told that no secondary check "pops up" requiring the Doctor to check the selection and confirm that is the prescription that was intended.

Mr Collinson, collapsed at 23.00 and suffered a cardiac arrest. 27 cycles of CPR were commenced and Thrombolysis given on the 11th cycle. Sadly, he could not be revived and he died at 02.14 on 15th June 2021.

Based on information from the Deceased's treating clinicians the medical cause of death was determined to be:

1a Pulmonary Embolism

1b Deep vein thrombosis

1c

II

1. The current system for allocating patients requires a manual check to see whether a patient has actually been seen once they have been allocated. If they are not seen, there is currently no way of other clinicians being aware of that, and therefore patients could be left for long periods of time without having been assessed.
2. The current electronic prescribing system does not require a Doctor to perform a secondary check that they have selected the correct medication. I am concerned that it is all too easy to select the wrong medication, particularly when the department is busy and Doctors are under pressure. This could lead to fatal outcomes for patients if given incorrect medication.