Rebekah Juliet Mills · Prevention of Future Deaths report

On 3rd August 2022 I commenced an investigation into the death of Rebekah Juliet Mills. The investigation concluded on the 6th February 2023 and the conclusion was one of Narrative: Died from post-operative complications of surgery following an accidental fall resulting in injury. The medical cause of death was 1a) Pulmonary Embolus; 1b) Post Meniscus Repair

Rebekah Juliet Mills had an accidental fall when skiing and she hurt her knee. She went to Stepping Hill Hospital and was seen in the Emergency Department. An examination identified no obvious injury. The notes did not capture her being on oral contraceptive or the degree of her lack of mobility. The virtual fracture clinic review on 13th June 2022 referred her to the physiotherapy team for an appointment.

Backlogs meant this did not take place as envisaged. On 22nd June she sought further help. She was seen on 11th July and a scan on 13th July identified a significant knee injury that had caused her knee to lock. She was seen on 21st July, and it was identified as repairable with surgery, but the surgery was urgently required. She was asked to stop taking oral contraceptive (a risk factor for surgery) which she did. On 28th July 2022 she was operated on. She was discharged home. On 1st August 2022 she collapsed and was taken to Stepping Hill Hospital where she died from a pulmonary embolism.

During the course of the inquest evidence was given that the guidance for clinicians in relation to reducing the risk of DVT when dealing with patients such as Ms Mills who are young and on oral contraception but are immobile following an accident and require surgery is unclear. That lack of clarity can give rise to a differing approach and a lack of recognition of the potential fatal risk that patients such as Ms Mills can face in such a situation.

The evidence was that greater clarity and greater understanding of the risks could prevent future deaths.