Adam Connolly Stuyvesant · Prevention of Future Deaths report

On 2 September 2022 I commenced an investigation into the death of Adam Connelly STUYVESANT.
The investigation concluded at the end of the inquest on the 6 October 2023. The conclusion of the inquest was:

Narrative Conclusion

On the 17 August 2022 Adam Connolly Stuyvesant was involved in a minor, single vehicle road traffic collision, on the Marlborough Road at Pewsey Wiltshire. He was admitted to The Great Western Hospital Emergency Department, Marlborough Road, Swindon, where in addition to minor injuries he was diagnosed with an avulsion fracture from the lateral malleolus in the left ankle. Adam was given a plastic boot to wear which immobilized the ankle. At that time, the DVT risk assessment had it been carried out would only have taken account of Adam's size, not the ankle immobility, which carried a risk of deep vein thrombosis.
On the 22 August 2022 Adam collapsed at Unit 31 Blackworth Industrial Estate, Highworth, Swindon and despite best efforts at resuscitation, died. The post mortem confirmed that death was due to the immobilisation of the left ankle allowing a deep vein thrombosis to develop which led to pulmonary embolus.

1a Pulmonary Embolus

1b Deep Vein Thrombosis

1c Lower Limb Immobilisation Secondary to Injury after Road Traffic Accident

II

See Box 3 above

(1) The wearing of a plastic boot can lead to lower limb immobility and the possibility of a restriction in the “calf pump function” which can lead to deep vein thrombosis.

(2) The DVT risk assessment in use in the Emergency Department at The Great Western Hospital, made no provision to take account of the immobilisation when considering whether anti-clotting medication should be prescribed.

(3) That without taking account of the immobility, as part of the DVT risk assessment, further patients may not be prescribed anti-clotting medication and as a result develop DVT, resulting in death from pulmonary embolus.