Winifred Mary Redfearn · Prevention of Future Deaths report

On the 21 January 2020 I commenced an investigation into the death of Winifred Mary Redfearn, otherwise known as Mary Redfearn and I then went onto open her Inquest on the 24 January 2020. On 19 June 2020 I concluded Mary's Inquest finding that the medical cause of death was:-

1a) Pulmonary thromboembolism
b) Deep vein thrombosis
c) Immobility due to head and neck injuries due to fall
2) Ischaemic heart disease

I recorded how, when and where Mary came by her death as follows: -

Winifred who was known by her middle name Mary died on the morning of 15 January 2020 at the Great Western Hospital in Swindon. A post mortem revealed that she died from a pulmonary embolism caused by a deep vein thrombosis attributable to her immobility in hospital after she was admitted to hospital following a fall down the stairs at home on 8 January 2020. As a result of the fall she injured her head and neck. Mary also had ischaemic heart disease which more likely than not contributed to her death.

CONCLUSION - Accident

I was satisfied on a balance of probabilities that the incident resulting in Mary's attendance at the Great Western Hospital occurred when she fell down the stairs at her home on Wednesday 8 January 2020. She attended the emergency department at the Great Western Hospital on Thursday 9 January 2020 at 2323 hours and was admitted the following day. As part of the evidence I had a statement from Locum Senior House Officer, and noted that mid-afternoon on 10 January 2020 as a result of a planned CT scan of the whole body the decision was taken to withhold venous thromboprophylaxis. The CT scan was completed and reported the same day at 1922 in respect of which the injury, in particular to her spine at C6, C7 was revealed.

The Pathologist, ████████ found at post mortem that the cause of Mary's death was as a result of developing a deep vein thrombosis as a result of immobility which then led to the development of pulmonary thromboembolism from which she died. Having reviewed the ████████ statement, I noted that despite the involvement of 3 other doctors on the evening of the 10 January 2020 that it was not until the afternoon on Monday 13 January 2020 was a request made to resume Dalteparin as part of the venous thrombosis prophylaxis.

I had no evidence before me to say more likely than not that it would have made a difference and having dealt with many cases similar to this, I fully recognise that even with venous thromboembolism prophylaxis, the risk of developing a deep vein thrombosis and subsequent pulmonary thromboembolism can never be completely excluded. That having been said I am, however, somewhat concerned that the resumption of Dalteparin took in excess of 2½ days from the production of the CT report and the delay would appear to be solely attributable to the weekend separating the point of which the Dalteparin was stopped and when it was resumed on Monday afternoon. Whilst I accept it may not have made a difference in this particular case, I am concerned that in other cases that such a delay could result in unnecessary premature death of a patient which is why I am raising this concern.