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
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
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.

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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

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