Karen Jane Winn · Prevention of Future Deaths report

On 25th April 2019 I commenced an investigation into the death of Karen Jane Winn

The investigation concluded at the end of the inquest on 15th October 2020. The conclusion of the inquest was that:-

Karen ‘Jane’ Winn died as the result of the progression of a naturally occurring illness, contributed too by the non-administration of medication to prevent blood clots from forming. This medication had been earlier identified as being essential for her treatment and the non-administration of this essential medication amounts to neglect.

The medical cause of death was confirmed as:

1a Bilateral pulmonary embolism
1b Deep venous thrombosis
1c Haemolytic anaemia

Karen ‘Jane’ Winn died on the 15th April 2019 at the West Suffolk Hospital, Bury St Edmunds in Suffolk.

Jane had been admitted 4 days earlier on the 12th April 2019.
On the 11th April 2019 Jane had visited her GP and had been diagnosed with a urinary tract infection and was prescribed antibiotics.

She returned to her GP the next day and was described as being ‘very unwell’. Her GP referred Jane straight to hospital.

Once in hospital, on the evening of the 12th April 2019 a medical consultant gave Jane a differential diagnosis of haemolytic anaemia, a serious and uncommon blood disorder.

It was identified that Jane had a risk of developing a Deep Vein Thrombosis (DVT) potentially leading to a pulmonary embolism. This is a known and life-threatening complication of haemolytic anaemia.

At the time of diagnosis on the 12th April a decision was made that Jane should be placed on prophylactic anticoagulation medication, as soon as results from a repeat set of blood tests had been obtained.

This repeat blood test (an INR test) was to ensure that any prophylactic anticoagulation medication would not increase Jane’s risk of internal bleeding.

Those blood test results became available later on the 12th April 2019, but at no time between then and the morning of the 15th April 2019 was prophylactic anticoagulation medication administered.

Subsequently, an automated VTE (Venous Thromboembolism) risk assessment warning system, embedded into the electronic patient case record, was manually overridden 58 times during Jane’s admission between the 12th and 15th April 2019.

A single dose of prophylactic anticoagulation medication was administered one hour prior to Jane’s death on the 15th April 2019, however this would not have been in a sufficient dose to breakup any blood clots that had already formed.

Jane was taken to the Intensive Care Unit on the morning of the 15th April 2019 but suffered a cardiac arrest and died shortly after arriving there.

A post-mortem examination confirmed widespread pulmonary emboli in Jane’s lungs and significant blood clots (DVT’s) in the veins in her upper legs.

The fact that Jane had not received the anticoagulant medication that she needed directly contributed to her death.

1. I am concerned that a differential diagnosis of a rare and serious blood condition (haemolytic anaemia), although identified soon after admission, was not escalated to a Haematology Consultant at the time this diagnosis was made. It was a rare condition, which by its very nature should be treated with the support of haematology specialists. I am concerned that those specialist were unaware that a differential diagnosis of serious blood disorder had been made without their specialist input.

2. In addition, I am concerned that the automated VTE assessment system does not appear to be significantly robust. I am aware that the WSH have taken steps to address the problem and have now placed the VTE assessment on the electronic Smart Zone ‘to do list’ and introduced an automated 14-hour consultant review function. However, I am concerned that as yet there is still no limit to the amount of times the automated ‘pop-up’ can be manually overridden and no automatic escalation process when it has been overridden a certain number of times.

3. I am further concerned that if a consultant at an early review has decided that prophylactic anticoagulation medication needs to be administered (even in the situation when a INR test is still awaited) that this is not clearly flagged on the patient electronic record in the Smart Zone, to act as a prompt for clinicians taking over that patients care.