Harry Glibbery · Prevention of Future Deaths report

On 15/04/2016 I commenced an investigation into the death of Harry Glibbery. The investigation concluded at the end of an Inquest on 15 August 2016. The narrative conclusion of the inquest was that Mr Glibbery died from a known complication (bleeding) of a necessary medical procedure (anti-coagulation)

Mr Glibbery suffered with a chronically infected left total hip replacement. He was under the care of ████████ Consultant Orthopaedic Surgeon whose efforts were greatly appreciated by the family. Mr Glibbery had a number of wash-outs as well as two first-stage revisions.
On 26th February 2016 he underwent a Girdlestone procedure.
On 4 March Mr Glibbery complained of shortness of breath and chest pain. A CT PA on 8 March revealed multiple pulmonary emboli as a consequence of which Mr Glibbery was started on Clexane. At Inquest I was advised that the Derriford Protocol provides for patients to be prescribed 1.5 milligrams per 1 kilogram once daily. As a matter of fact, I found that Mr Glibbery was prescribed 1 milligram per kilogram administered twice daily. Upon admission into hospital Mr Glibbery weighed 80 kilograms and, as a consequence, he received 160 milligrams of Clexane daily instead of 120 milligrams.
I was advised that the prescription was reviewed on 3 separate occasions by Pharmacy clinicians but the error was not identified.
On 5 April Mr Glibbery deteriorated acutely and a CT scan revealed a catastrophic intracerebral haemorrhage from which he died on 7 April 2016.
As a matter of fact I found that the over-administration of Clexane did not cause the death but it may have contributed to the outcome in the sense that once the intracerebral haemorrhage started it bled more profusely than would otherwise have been the case.

(1) The doctor who originally prescribed the Clexane did not do so in accordance with Derriford Protocol;
(2) The doctor’s prescription error was not identified during Pharmacy reviews intended to pick up precisely this sort of shortcoming;
(3) I was advised that during Mr Glibbery’s admission he lost a substantial amount of weight estimated at between 6 – 10 kilograms. ████████ (who gave evidence) expressed their difficulties in having patients weighed. This is particularly difficult for patients who have undergone hip replacements where, I was told, a hoist that is available is not high enough to return patients back to their beds. The importance of this is obvious in patients whose medication is weight-dependent. It is believed that Mr Glibbery was on the cusp of requiring a downward review of the amount of Clexane prescribed to him.