David Andrew Bladen · Prevention of Future Deaths report

On 04/09/2014 I commenced an investigation into the death of David Andrew Bladen, 58 . The investigation concluded at the end of the inquest on 13 January 2015. The conclusion of the inquest was Narrative conclusion. The cause of death was :
1a. Pulmonary embolism
1b. Deep vein thrombosis
1c. Ruptured right quadriceps (Operated in July 2014)

Mr Bladen ruptured his quadriceps tendon after falling down some stairs on 14th July 2014. He underwent surgery to reconstruct the right quadriceps tendon. He was provided with mechanical thromboprophylaxis during surgery and post operatively received two doses of medication thromboprophylaxis before being discharged two days post surgery. He was prescribed no extended prophylactic treatment on discharge and further assessments led to no further treatment being provided for thromboprophylaxis. Mr Bladen died on 2nd September 2014 from a massive pulmonary embolism. During the course of evidence I not only heard from doctors who had been involved in Mr Bladen's care and the issue of thromboprophylaxis but also from a specialist in this area ████████ It became clear during the evidence I heard that although NICE provides guidance in relation to the need for extended prophylaxis in certain cases e.g. where a patient has been given a cast, there is no clear guidance for patients in a brace. (As was the case with Mr Bladen) and there are many arguments to say that such patients are at as much risk as developing thromboembolism as those with casts. Medics who gave evidence at the inquest were in agreement that the NICE guidelines does not provide advice as to what is the best thromboprophylaxis management for these categories of patients.

(1) Absence of guidance for optimum thromboprophylaxis management in patients who are not in casts but still have restriction of mobility eg. due to a brace.