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Investigation and inquest
Kathryn Lynda Millard died on 13 May 2021 at the Medway Maritime Hospital. An investigation into her death was commenced. The investigation concluded at the end of the inquest on 28 March 2022.
The jury found that the medical cause of death was:
1a Pulmonary Embolism
1b Deep Venous Thrombosis
1c
II Fractured Spine, Diabetes Mellitus
The jury’s conclusion was that Ms Millard’s death was an accident. They gave a short narrative conclusion in addition, which read:
She died from a complication of necessary medical treatment.
Circumstances of the death
On the 10th May 2021 Kathryn Millard fell backwards down a flight of stairs at a property where she was working. She was admitted to Medway Maritime Hospital with a fractured spine.
At Medway Maritime Hospital, she was immobilised upon admission and a decision was made that she should be prescribed stockings to avoid deep vein thrombosis and dalteparin as prophylaxis.
The stockings were not applied. In respect of dalteparin, this was a decision initially withdrawn due to an identified risk of bleeding and the prospect of surgery. When it was determined that there was to be no surgery, the treating consultant indicated that dalteparin should be commenced. That decision was not recorded in Mrs Millard’s medical notes. The dalteparin was not given.
On 12 May 2021, Mrs Millard began to have green vomit. The nursing staff were concerned and asked for her to be reviewed by a doctor. An unidentified individual came to the ward and saw Mrs Millard. That individual did not record their interaction in Mrs Millard’s notes nor did they speak with the nursing staff.
On the morning of 13 May 2021, Mrs Millard had a cardiac arrest. Despite efforts by staff, she could not be resuscitated.
Coroner’s concerns
(1) The direction of the most senior clinician, the orthopaedic surgeon, was not documented in the medical records and was not implemented. It is concerning that this treatment plan was not recorded properly in the deceased’s notes.
(2) The medical records indicated that at least one doctor had indicated that Mrs Millard should have anti-embolic stockings applied. However, the nursing staff gave evidence that they were not aware of this.
(3) The nursing staff were concerned on the 12 May 2021 as to the presentation and prognosis of the deceased. Whomever attended (if they anybody did in fact attend), did not make any entry into Mrs Millard’s medical records. It is concerning that the Trust were not able to identify this individual and that they did not discuss the patient’s presentation and prognosis with the nursing staff.
Information checked against the published report and official responses