John Thorp · Prevention of Future Deaths report

On 15 February 2018 an investigation was commenced into the death of John Thorp, then aged 79. The investigation concluded at the end of the inquest on 15 February 2019. The conclusion of the inquest was natural causes, the medical cause of death being 1a) Pulmonary thromboembolism 1b) Deep vein thrombosis and 2) Right lower lobe pneumonia (recent treated legionella pneumonia), cardiomyopathy.

(1) Mr. Thorp became unwell in early January 2018 and was admitted to the Acute Medical Unit at Ealing hospital on 9th January 2018 with a diagnosis of community acquired pneumonia. He was very unwell and underwent treatment with intravenous fluids, antibiotics and oxygen therapy. He was also commenced on Tinzaparin and prescribed TED (thrombo-embolic deterrent) stockings.
(2) On the 10th January 2018 he deteriorated and was admitted to the Intensive care unit. He was ventilated and spent over two weeks in the Intensive Care Unit where he slowly improved and he was discharged to ward 6 North on 26 January 2018.
(3) He deteriorated again on the 28 January 2018 with signs of a further chest infection which was treated appropriately with antibiotics and he went on to make a slow recovery, with his oxygen being weaned and a general improvement in his condition, such that plans for discharge were being made on 6 February 2018.
(4) In the early hours of 8 February 2018 he deteriorated and became increasingly breathless. He was appropriately escalated and seen by a junior doctor who prescribed intravenous diuretics and ordered a chest x-ray. Before the latter could be performed Mr. Thorp suffered a cardiac arrest from which he could not be resuscitated and he died on the 8 February 2018.

(1) Evidence given at the inquest by a senior nurse and Consultant indicated that only a doctor could prescribe TED stockings. There were three different prescriptions for TED stockings in the three different areas where Mr Thorp was treated. The standard ward based drug chart had a tick box in the low molecular weight heparin box on the drug chart for whether TED stockings were indicated.
(2) Evidence was given at the inquest that the medical staff where inconsistent in how they prescribed TED stockings. One of Mr Thorp’s drug charts had simply a tick in the box indicating there were required but there was nowhere for nursing staff to sign if they were given. Another drug chart had a separate prescription with the stockings being written up as a regular item and nurses could fill in the prescription chart to indicate if they had been given, or if not given the reasons why not.
(3) There was evidence given that this inconsistency in the way in which medical staff prescribed TED stockings may lead to stockings being prescribed but not given which may in turn increase the risk of thromboembolic formation.