Karen Ravenscroft · Prevention of Future Deaths report

On the 17th day of March 2016 I commenced an investigation into the death of Karen Elizabeth Ravenscroft aged 60 years. The investigation concluded at the end of the Inquest which was concluded on the 18th day of May 2016. The conclusion of the Inquest was that Karen Ravenscroft had died an accidental death.

On the 11th March 2016 Karen Ravenscroft fell at her home address and fractured both her left arm and left leg. At the Royal Blackburn Hospital she was assessed of high risk of development of deep vein thrombosis. She was not provided with the appropriate prophylaxis and developed a deep vein thrombosis which caused a fatal pulmonary embolus.

1. The initial venous thromboembolism risk assessment done during the admission as per the Trust’s VTE Guidelines stated that Mrs Ravenscroft was at high risk for VTE with no bleeding risk and no contra-indication for pharmacological thromboprophylaxis. Despite that no thromboprophylaxis was prescribed.

2. Despite Trust VTE Guidelines recommending re-assessment of VTE risk at 24 hours after admission, no further risk assessment took place nor was there application of mechanical thromboprophylaxis like Ted Stocking or Flowtron Pump.

3. Evidence revealed that drugs prescribed in the Accident & Emergency Department could not be done electronically without the doctor going on the ward in order to be able to do that.