Source · Prevention of Future Deaths
Nicholas Megginson
Ref: 2014-0400
Date: 11 Sep 2014
Coroner: Andrew Barkley
Area: Powys, Bridgend & Glamorgan Valleys
Responses identified: 0 / 1
View PDF
Patients discharged post-surgery received inconsistent advice, both oral and written, regarding venous thromboembolism risks and critical signs requiring urgent medical attention.
Date
11 Sep 2014
56-day deadline
5 Nov 2014
Responses identified
0 of 1
Coroner's concerns
Patients discharged post-surgery received inconsistent advice, both oral and written, regarding venous thromboembolism risks and critical signs requiring urgent medical attention.
View full coroner's concerns
1. The evidence revealed that there was no consistent advice given to patients discharged post-surgery regarding the risks of venous thromboembolism either orally or in writing incorporating advice in relation to concerning clinical signs which may arise to indicate urgent medical treatment is required.
Report sections
Investigation and inquest
On the 28 th May 2014 I commenced an investigation into the death of Nicholas James Megginson, aged 45 years. The investigation concluded at the end of an inquest on the 6th August 2014. The conclusion of the inquest was that of a narrative conclusion; "Nicholas James Megginson died from effects of apulmonary thromboembolism arising from him fracturing his ankle when he fell on the 51 May 2014. He was considered high risk for developing a thromboembolism by virtue of the fracture and his underlying vascular impairment. Whilst he was prescribed prophylaxis for venous thromboembolism which was administered after his surgery on the elh May, he was not prescribed anything thereafter" The medical cause of his death was recorded as: 1a. Pulmonary Thromboembolism 1b. Deep Venous Thrombosis 1c. Fractured Left Ankle (operated 06/05/2014)
Circumstances of the death
The deceased was found unresponsive by his wife at the home address on the 22nd May 2014. He had ~reviously fractured his left ankle on the 51h May 2014 and had an operation on 61 May before being discharged home on yth May. A post mortem examination found that he had died from the effects of a pulmonary embolism.
Similar PFD reports
Related inquiry recommendations
Muckamore Abbey Inquiry
Consultation before patient transfers
Muckamore Abbey Inquiry
Independent living skills focus
Mid Staffs Inquiry
Continuing responsibility for care
Bristol Heart Inquiry
Establish comprehensive counselling and support services as integral to patient care
COVID-19 Inquiry
Standardised Advance Care Planning
Muckamore Abbey Inquiry
Person-centred day activities and supported employment
Muckamore Abbey Inquiry
Meaningful daily activities
Muckamore Abbey Inquiry
Person-centred care plans with family involvement
Muckamore Abbey Inquiry
Co-production training
Muckamore Abbey Inquiry
Co-production processes and clinical audit
Report details
- Reference
- 2014-0400
- Date of report
- 11 September 2014
- Coroner
- Andrew Barkley
- Coroner area
- Powys, Bridgend & Glamorgan Valleys
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 Nov 2014.
Sent to
- Cwm Taf Health Board