“The Level Two Comprehensive Investigation of the Worcestershire Acute Hospitals NHS 5…”

The coroner’s concerns

– 1. The Level Two Comprehensive Investigation of the Worcestershire Acute Hospitals NHS 5 Trust ('WAH') concluded the root cause of Jack's death was: “There was no official national guidance and no approved Trust guidance on managing VITT in place at the time this patient was admitted to AGH, therefore staff are unlikely to have been aware of the timecritical need to transfer the patient to a specialist centre (QEHB).” The following care and service delivery problems were identified: “There was no written Trust or national guidance on managing VITT at the time the patient was admitted, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB).” The following Contributory factors were identified: - The Neurosurgical team at QEHB were contacted for advice; had the Trust VITT guidance been in place at the time, it would have stipulated not to contact the Neurosurgical team, but instead to contact Haematology and Neurology at QEHB. - The Neurosurgical team at QEHB advised to continue medical management locally (at WAHT). - Had the Trust VITT guidance been in place at the time, the WAHT Haematologist would have been prompted to contact their counterpart Haematologist at QEHB which may have accelerated the process of transfer; this did not happen until the day after the patient’s admission. 2. Within the course of the evidence at the inquest it was identified that, whilst there was no NICE Guidance or a local policy at WAH, there was a number of publications on the management of VITT and patients presenting with complications post Astra Zeneca Vaccination: i. Guidance from the Expert Haematology Panel (EHP) on Covid-19 Vaccine-induced Immune Thrombocytopenia and Thrombosis (VITT) 28th May 2021 ii. Joint guidance from the Royal College of Emergency medicine, the Society for Acute Medicine and the Royal College of Physicians 'Management of patients presenting to the Emergency Department/ Acute Medicine with symptoms 5-42 days post Astra Zeneca vaccine' 24th May 2021 iii. 'Management of Cerebral Venous Sinus Thrombosis following COVID-19 vaccination. A neurosurgical guide.' from the British Society of Neurological Surgeons 19th April 2021 3. Evidence also identified that the University Hospitals Birmingham NHS Foundation Trust had also put in place a Regional VITT Pathway that was communicated to Haematologists and Neurologists across the region in March 2021. Prior to Jack's admission to the Alexandra Hospital on the 8th June 2021 4 patients had been transferred from the WAH to the QEH under the pathway including 1 patient from the Alexandra Hospital. 4. The WAH investigation did not identify the above guidance or Pathway and did not provide any explanation of why they were not followed in Jack's case. 5. Concerns were raised in the management of Jack's care whilst at the Alexandra Hospital, in particular the emergency department decision to refer to the medical and not neurology team, the level of observations whilst on ward 11 and the fact that family were reporting a concern that Jack was deteriorating during the afternoon of the 9th June 2021. The WAH investigation report does not record that these matters (or any other aspect of clinical care) were investigated, the conclusions reached or the bass for those conclusions. 6. This raises a concern that the investigation was not sufficient and as such has not served its purpose of safeguarding patients. 7. No adequate explanation was given in evidence to explain why the investigation was incomplete. 8. If WAH serious incident investigations are not sufficient the lessons arising will not be identified and necessary action will not be taken putting lives at risk.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2022-0167

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0