Alan Kinsbury

I am Karen HENDERSON, Assistant Coroner for the coroner area of West Sussex, Brighton and Hove

On 21 st February 2024 I concluded an investigation into the death of Dr Alan William Kingsbury. The medical cause of death recorded was:- 1a Pneumonia 1b Fractured right neck of femur (repaired surgically 21/10.23) 1c Fall secondary to anaemia, secondary to bleeding chest wall lesion (excised squamous cell cancer 19.10.23) 3 Severe frailty of Old Age I returned a narrative conclusion: Dr Alan William Kingsbury was extremely frail with poor physiological reserve. On the 19th October 2023 he was admitted into Worthing Hospital, Worthing as an emergency for excessive bleeding secondary to an excision of a left cutaneous chest lesion (squamous cell carcinoma in situ) earlier that day whilst anticoagulated with aspirin and clopidogrel. In the early hours of 21st October 2023 Dr Kingsbury had a fall in the hospital in circumstances whereby neither a sitting and lying blood pressure or a falls assessment had not been undertaken.  He sustained a right neck of femur fracture requiring surgical repair later that day alongside further surgical revision of the chest wound for dehiscence and ongoing bleeding. The combination of frailty, ongoing bleeding from the chest wound and complications of the fall all contributed to his death at the hospital on 29th October 2023

The conclusion reflects the circumstances of Dr Kingsbury’s death.

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.  In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:

1. BSDS (British Society of Dermatological Surgery) Guidelines on Anti-

thrombotics and skin surgery for dermatological excisions in the community . The guidelines as to the suitability of maintaining patients’ anti-thrombotic medication prior to surgical excision are insufficiently robust to reflect bleeding potential from a myriad of factors including the condition of the skin being excised, the position of the lesion and the underlying frailty and medical co-morbidites of individuals requiring dermatological surgery in the community.  Dr Kingsbury was extremely frail taking Aspirin and Clopidogrel. The lesion to be excised was on the upper chest wall with extremely fragile skin and the excision was larger than expected with some difficulty in obtaining primary closure.

1. The lack of a Preoperative assessment and advanced consent

Dr Kingsbury was not assessed or consented either in person or by telephone consultation prior to the day of the procedure against current accepted guidelines for surgical procedures. No risk/benefit analysis was undertaken as to the suitability of undertaking the procedure whilst Dr Kingsbury was taking Aspirin and Clopidogrel. Mrs Kingsbury made multiple attempts at communicating with the service without success to obtain advice as to the necessity or otherwise of discontinuing the anticoagulants.

1. Guidance as to the appropriateness of the surgical technique for wound closure

Evidence was heard that due to the fragility of the skin the initial wound  closure was not sufficiently deep to effectively achieve haemostasis, requiring closure at a muscular level with different suture technique.

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.