Source · Prevention of Future Deaths
Margaret Heal
Ref: 2024-0368
Date: 6 Dec 2023
Coroner: James Thompson
Area: Durham & Darlington
Responses identified: 0 / 1
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A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting a gap in discharge advice for at-risk individuals.
Date
6 Dec 2023
56-day deadline
24 Sep 2024 est.
Responses identified
0 of 1
Coroner's concerns
A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting a gap in discharge advice for at-risk individuals.
View full coroner's concerns
During the course of the inquest it became apparent there was no evidence to show the deceased had been provided with a document instructing her to resume her anti coagulation. Whilst this requirement is set out in the Trust's procedures, no evidence was found it had taken place. No document was found in Mrs Heal's home at the time of her death. It is of concern that Mrs Heal was an 86 year old lady living alone after her discharge from hospital. Is there more that can be done to ensure patients particularly who are vulnerable and / or elderly are given advice regarding recommencement of drugs in a manner, to ensure as far possible, they are aware of the need to recommence their medication.
Report sections
Investigation and inquest
On 25/07/2022 14:17an investigation was commenced into the death of Margaret HEAL 30/07/1935 00:00:00. The investigation concluded at the end of the inquest on 06/12/2023 00:00. The conclusion of the inquest was that Margaret Heal died on 12th July at her home, from a massive pulmonary thromboembolism which had caused by a deep venous thrombosis. This is a natural disease running its full course and resulting in her death. She had stopped taking her anti-coagulant medication on medical advice 10 days prior to her death to undergo surgery. She did not resume this medication after it. It is unclear on the evidence if she was unaware of the need to resume the medication or she chose not to resume the medication..
Circumstances of the death
Margaret Heal died on 12th July at her home, from a massive pulmonary thromboembolism which had caused by a deep venous thrombosis. This is a natural disease running its full course and resulting in her death. She had stopped taking her anti-coagulant medication on medical advice 10 days prior to her death to undergo surgery. She did not resume this medication after it. It is unclear on the evidence if she was unaware of the need to resume the medication or she chose not to resume the medication.
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Report details
- Reference
- 2024-0368
- Date of report
- 6 December 2023
- Coroner
- James Thompson
- Coroner area
- Durham & Darlington
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Sep 2024 (estimated).
Sent to
- The Trust