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Desrae Tucker

Ref: 2014-0032 Date: 23 Jan 2014 Coroner: Wendy James Area: Gwent Responses identified: 0 / 1 View PDF

Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge were issues.

Date 23 Jan 2014
56-day deadline 20 Mar 2014 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge were issues.
View full coroner's concerns
_ The lack of recording in the patient's notes as to whether the patient was wearing the anti-embolic stockings prescribed No consideration given as to whether the patient should be discharged home with anti-embolic stockings gall

(3) No anti-coagulant medication prescribed to the patient upon discharge

Report sections

Investigation and inquest
On 28-03-13 commenced an investigation into the death of DESRAE REGINA TUCKER (do.b 18/06/44). The investigation concluded at the end of the inquest on the 04-12-13. The conclusion of the inquest was that Desrae Regina Tucker died as result recognised complication following necessary surgical procedure the medical cause of death being: (a) Pulmonary embolism Deep vein thrombosis Recent Cholecystectomy (operated)
Circumstances of the death
On 12-03-13 Mrs. Tucker was admitted as an emergency to the Royal Gwent Hospital with abdominal pain: She subsequently underwent surgery for removal of her bladder on 20-03-13_ She was discharged home on 24-03-13 and died at home on 26-03-13.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.
Copies sent to
14 WJam . duty either =

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Report details

Reference
2014-0032
Date of report
23 January 2014
Coroner
Wendy James
Coroner area
Gwent

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: 20 Mar 2014 (estimated).

Sent to

Aneurin Bevan Health Board

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.