Fatal blood clot could have been prevented

Mrs B was elderly, had arthritis, osteoporosis and a degenerative spine condition. She had developed a blood clot after breaking her ankle.

Four years later, Mrs B fell downstairs. She broke two bones in her neck and doctors also suspected a broken bone in her foot. She was given a neck collar and an Aircast boot to support and immobilise the injured areas. She was told to keep mobile, and physiotherapy helped with that. She was admitted to an orthopaedic ward.

Mrs B was at high risk of developing blood clots because of her age, weight and medical history. Doctors decided not to give her blood thinning medicine due to the risk of bleeding into the neck fracture, which could have been fatal. Instead, they prescribed tight-fitting stockings to help prevent the formation of blood clots in leg veins.

Just over two weeks after being admitted, Mrs B collapsed. Attempts to resuscitate her failed. Mrs B's family had been expecting her imminent discharge to a residential care home, so this came as a great shock. The main cause of Mrs B's death was a pulmonary embolism which had come from a clot in a leg vein. She had also suffered a heart attack.

Mrs B's son, Mr S, complained to the Trust about his mother's care and treatment, communication, access to the consultant and discharge arrangements. He said his mother's death could have been prevented. The Trust gave written responses and two meetings were held. An inquest also took place. Mr S was not satisfied with the Trust's responses and its handling of his complaint. He wanted to know what had happened to his mother and he wanted the Trust to learn lessons and make improvements.

What we found

We upheld some parts of this complaint.

The Trust did not adequately manage Mrs B's risk of developing an embolism. She would probably not have developed one if she had been managed in line with national guidelines. Clinicians should have reassessed her when the risk of bleeding into the spinal fracture had reduced and they should have given her an anticoagulant (blood thinning medicine). Mrs B's ability to move about was very restricted due to pain, the collar and boot, and her pre-existing conditions. The tight-fitting stockings and very limited movement were not enough to prevent clots forming.

Doctors did not prescribe two drugs that Mrs B took regularly at home and did not document any reasons for this. One drug was aspirin, which Mrs B took to reduce the risk of heart attack and stroke. We found that it was more likely than not that she would still have had a heart attack even if she had been taking these drugs in hospital. In other words, she would have died of the heart attack, even if the embolism had not happened.

The Trust did not adequately explain the clinical situation and plan of care to Mrs B and Mr S, and the records did not show a reasonable level of supervision from senior doctors. Nurses responded appropriately to Mrs B's deterioration in the days before she died. There were no failings in physiotherapy or discharge planning, apart from a lack of senior review to confirm that Mrs B was medically fit to be discharged.

We found failings in complaint handling. In particular the Trust should have clarified with Mr S at the beginning all the issues he wanted its investigation to cover.

Putting it right

The Trust acknowledged and apologised for its failings and for the impact they had. The Trust agreed to share our investigation report with the healthcare professionals involved in Mrs B's care and with the complaint handlers so that lessons could be learned. It also agreed to identify whether the arrangements in place for consultant orthopaedic follow up of patients and supervision of junior doctors were robust.