Francoise Simone Annabel SNAPE · Prevention of Future Deaths report

On 14th August 2014 I commenced an investigation into the death of Francoise Simone Annabel SNAPE then aged 59.
The investigation concluded at the end of the inquest on 11th February 2015.
The conclusion of the inquest was she died as the result of a known complication of necessary medical treatment the medical cause of death being a) left intracerebral haemorrhage 1b) massive pulmonary embolus (thrombosed) 1c) left middle cerebral artery territory infarction.

On the 2nd August 2014 Mrs Snape was admitted into Worcestershire Royal Hospital following an infarcted stroke.

She was managed conservatively until 11th August when she developed a massive pulmonary embolus.

Thromboembolic medication was given which caused a catastrophic bleed resulting in her death.

(1) No VTE assessment was ever made of Mrs Snape. The explanation given by ████████ was that staff were too busy to complete the form and that because she had had a stroke heparin could not be given and therefore the paperwork was unnecessary.
(2) NICE guidelines regarding the use of mechanical anti DVT devices instead of heparin in high risk cases was not considered. ████████ indicated in his evidence that the guidance on such matters was to be found in "general" guidance regarding DVTs and not in "stroke" guidance. The clear difference was that he was not aware of the content of the general guidance despite it being specifically referred to as involving stroke patients.

It was clear in the Inquest that the absence of a formally completed VTE assessment and lack of knowledge of NICE guidelines amounted to a lost opportunity to make informed decisions for the care of Mrs Snape which may (but only may) have changed the outcome for her.

(3)