Stephen Anthony Mayoll · Prevention of Future Deaths report

On 28th June 2013 I commenced an investigation into the death of Stephen Anthony Mayoll, aged 44. The investigation concluded at the end of the inquest on 19th November 2014. The conclusion of the inquest was:
Narrative Conclusion:
1- On 10th June 2013 Stephen Anthony Mayoll fell from a ladder at work and sustained a right Achilles tendon injury for which he received treatment as an out-patient at Queen Alexandra Hospital, Portsmouth, between 11th and 20th June 2013.
2- On 21st June 2013 he became very unwell at home and was taken by ambulance to Queen Alexandra Hospital where he died at 03.20 hours on 22nd June 2013.
3- He died as a result of complications of his injury and its treatment at the hospital between 11th and 20th June 2013, namely a pulmonary thromboembolism arising from a deep vein thrombosis in his right lower leg. Mr Mayoll did not fulfil the criteria then in force at the hospital for the use of anti-coagulation therapy in respect of Achilles tendon injury patients and in consequence did not receive such therapy which, on the balance of probabilities, would have reduced the risk of those complications arising.

The circumstances of Mr Mayoll's death are set out in Paragraph 3 above.

1- Out-patients with similar injuries to Mr Mayoll's returning to the fracture clinic at Queen Alexandra Hospital experiencing problems with their treatment or for periodic review are not subject to re-assessment under the hospital's DVT assessment policy. If they were, there would be less risk of their developing DVT's during the course of their treatment.
2- Evidence was given at the Inquest highlighting the delay in typing fracture clinic doctors' notes meaning that they would not always be available if an out-patient returned to the clinic and improved methods of making the notes available sooner to the clinic (e.g. by use of voice recognition IT) would obviate this problem.