Julie Louise Hancock · Prevention of Future Deaths report

In March 2022, I commenced an investigation into the death of Julie Louise Hancock, aged 53, who died on 28/3/22. The investigation has not yet concluded and the inquest was adjourned today after the matters I am writing to you about came to light.

Julie had a past medical history that included rheumatoid arthritis and hypertension. In December 2021, she was offered staged bilateral knee replacements. She was assessed by ████████ as being at high risk of developing a DVT.

She had a nurse-led pre-op assessment on 26/1/22 when, I am told, a further risk assessment was not done, in accordance with policy at the time.

On 2/3/22, she had a right total knee replacement. She was discharged on 5/3/22 and died at home on 28/3/22. At post-mortem, her cause of death was found to be:
1a) Pulmonary embolus
1b) Deep vein thrombosis
II) Immobility following right knee replacement

I enclose the bundle of evidence.

At pp A32-A54, you will find what I am told is the Trust’s Guideline Summary for Thrombosis Prevention and Anticoagulation. At p42, following elective knee replacement, it is suggested clinicians may choose any one of
Aspirin ████████ for 14 days
LMWH for 14 days and anti-embolism stockings
Rivaroxaban ████████ once daily for 14 days

As matters of fact, I am told Mrs Hancock was prescribed 14 days of aspirin, an apparent error, one unidentified doctor also prescribed Dalteparin which was stopped after a single dose. It is of concern that the doctor cannot be identified and I have no record of the decision-making.

At C32, you will find the Trust’s full guidance for drug prophylaxis following elective knee replacement which is taken from its Thrombosis Prevention and Anticoagulation Policy v9.0 dated Feb 2022. It provides:

Low risk – Aspirin ████████ daily for 14 days
High Risk – Rivaroxaban ████████ daily for 14 days or
Dalteparin or Enoxaparin for 28 days plus stockings (until discharge.)

████████ had not seen the full guidance previously despite it having been published for over a year which, as a consultant orthopaedic surgeon, is of concern in itself.

█ further said that Mrs Hancock was high risk yet she appears to have been given prophylaxis for a low risk patient because the summary guidelines appear not to reflect accurately the full guidance.

████████, as I understood ███, said that it had been █ practice to prescribe aspirin to all high-risk patients since (at least) February 2022. This raises the question of whether other patients have died from a PE or DVT because of wrongly prescribed prophylaxis that have not been reported to this Office. You will need to consider the position.

I have only considered the situation as it came before me, namely, for an elective knee replacement. As I understand the anticoagulation policy will have a much wider reach than that there is an obvious need to consider the implications across all the Trust’s services.