Amy Anderson, solicitor in the clinical negligence and personal injury team, represented the daughters of a 79 year old man, whose tragic death was the subject of an inquest at West London Coroner's Court on 15 February 2019.

The Deceased had little by way of previous medical history at the time of his admission to Ealing Hospital on 9 January 2018. He sadly died following a cardiac arrest from which he could not be resuscitated on 8 February 2018. The principal medical cause of death was recorded as pulmonary thromboembolism secondary to deep vein thrombosis.

The Facts

On arriving at hospital, the Deceased underwent a standard risk assessment designed to address the risk of venous thromboembolism ('VTE'). VTE is a term which is used to encompass conditions arising from blood clots, including deep vein thrombosis and pulmonary embolism, which can be fatal. These conditions can develop in medical patients in part due to their immobility if they are bed-bound during their stay in hospital.

The Deceased was deemed to be at risk of VTE and was prescribed with thromboembolic deterrent stockings (or 'TED stockings') in addition to anticoagulant medication that helps to prevent the formation of blood clots.

In the three different areas of Ealing Hospital where the Deceased was treated, he was prescribed with TED stockings.

Evidence given at inquest by a senior nurse and consultant from the Trust revealed that there was inconsistency in the way in which medical staff prescribed TED stockings.

One of the drug charts that was used had separate boxes for the prescription of the anticoagulant medication and the TED stockings. Another of the drug charts had only one box for both the medication and TED stockings and no room for nurses to indicate whether TED stockings had been given and if not, why not.

The Coroner felt that the Trust's inconsistent practice in this regard gave rise to concern that TED stockings may be prescribed but not given, thereby increasing the risk of the formation of VTE.

Prevention of Future Deaths

Where a coroner considers that their investigation has revealed risk that other deaths will occur in the future if action is not taken, they have a statutory duty to report the matter to the person or organisation that they believe may have the power to eliminate or reduce that risk.

In this case, the Coroner issued a Prevention of Future Deaths report to London North West University Healthcare NHS Trust encouraging it to take action to address the concerns revealed by her investigation, namely:

  1. the inconsistency in how medical staff at the Trust prescribed TED stockings
  2. the inconsistencies in the drug charts used for the prescription of TED stockings

Once a coroner makes a report of this nature, a written response is required from the party to whom it is addressed.

In this case, the Trust provided a response to the Coroner's report indicating that it has formulated a new, standardised way of prescribing TED stockings for use across London North West University Healthcare NHS Trust. This has been shared at Trust level, with junior doctors being informed via the Medical Education Department and the new information being circulated to all clinical staff via memoranda and in the Trust-wide newsletter.

Whilst it will often be little consolation to families whose relatives have died in tragic circumstances, the coroner's duty to report on concerns giving rise to a risk of future deaths is an important coronial responsibility, which can lead to positive action and change in the future.