Source · Prevention of Future Deaths
Adam Stuyvesant
Ref: 2023-0372
Date: 6 Oct 2023
Coroner: Ian Singleton
Area: Wiltshire and Swindon
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe DVT risk assessment in the Emergency Department at The Great Western Hospital did not account for lower limb immobility caused by plastic boots when considering anti-clotting medication. This gap could result in other patients developing deep vein thrombosis leading to pulmonary embolus.
Date
6 Oct 2023
56-day deadline
5 Dec 2023
stated in the report
Responses identified
0 of 1
Coroner's concerns
The DVT risk assessment in the Emergency Department at The Great Western Hospital did not account for lower limb immobility caused by plastic boots when considering anti-clotting medication. This gap could result in other patients developing deep vein thrombosis leading to pulmonary embolus.
View full coroner's concerns
(1) The wearing of a plastic boot can lead to lower limb immobility and the possibility of a restriction in the "calf pump function" which can lead to deep vein thrombosis.
(2) The DVT risk assessment in use in the Emergency Department at The Great Western Hospital, made no provision to take account of the immobilisation when considering whether anti-clotting medication should be prescribed.
(3) That without taking account of the immobility, as part of the DVT risk assessment, further patients may not be prescribed anti-clotting medication and as a result develop DVT, resulting in death from pulmonary embolus.
(2) The DVT risk assessment in use in the Emergency Department at The Great Western Hospital, made no provision to take account of the immobilisation when considering whether anti-clotting medication should be prescribed.
(3) That without taking account of the immobility, as part of the DVT risk assessment, further patients may not be prescribed anti-clotting medication and as a result develop DVT, resulting in death from pulmonary embolus.
Report sections
Investigation and inquest
On 2 September 2022 I commenced an investigation into the death of Adam Connelly STUYVESANT. The investigation concluded at the end of the inquest on the 6 October 2023. The conclusion of the inquest was: Narrative Conclusion On the 17 August 2022 Adam Connolly Stuyvesant was involved in a minor, single vehicle road traffic collision, on the Marlborough Road at Pewsey Wiltshire. He was admitted to The Great Western Hospital Emergency Department, Marlborough Road, Swindon, where in addition to minor injuries he was diagnosed with an avulsion fracture from the lateral malleolus in the left ankle. Adam was given a plastic boot to wear which immobilized the ankle. At that time, the DVT risk assessment had it been carried out would only have taken account of Adam's size, not the ankle immobility, which carried a risk of deep vein thrombosis. On the 22 August 2022 Adam collapsed at Unit 31 Blackworth Industrial Estate, Highworth, Swindon and despite best efforts at resuscitation, died. The post mortem confirmed that death was due to the immobilisation of the left ankle allowing a deep vein thrombosis to develop which led to pulmonary embolus. la Pulmonary Embolus lb Deep Vein Thrombosis le Lower Limb Immobilisation Secondary to Injury after Road Traffic Accident II
Circumstances of the death
See Box 3 above
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Report details
- Reference
- 2023-0372
- Date of report
- 6 October 2023
- Coroner
- Ian Singleton
- Coroner area
- Wiltshire and Swindon
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: 5 Dec 2023 (stated in the report).
Sent to
- Great Western Hospital