Mr Robert Dymond · Prevention of Future Deaths report

On 23 March 2017, I commenced an investigation into the death of Mr Robert Dymond, aged 61. The investigation concluded at the end of the inquest on 20 July 2017. The medical cause of death was found to be:
1a Pulmonary Thromboembolism
1b Deep Vein Thrombosis
1c Obesity and Recent Surgery for Knee Replacement

The Conclusion of the inquest was a Narrative Conclusion:

Died from a recognised complication of surgery.

On 20 May 2015, Mr Dymond has been placed on the waiting list for elective left knee replacement surgery. As he was considered to be a high risk patient owing to his previous medical history, which included a high BMI of 42.1, he had to undergo this at UHCW which has a Critical Care Unit. He had an initial pre-op assessment on 21 July 2016 and a further pre-op assessment on 12 January 2017. Despite the fact that he had undergone investigation and preliminary treatment for a suspected DVT in November 2016 at UHCW, I was informed that the pre-op assessment in January 2017 had not changed since the previous one. The Consultant Orthopaedic Surgeon performing the surgery was not informed of the events in November 2016. The surgery was performed on 9 March 2017. On the morning of 10 March 2017, and despite appropriate post-operative VTE prophylaxis, he suffered a massive thromboembolic event and passed away on 11 March 2017.

(1) Following referral to the UHCW DVT Clinic by his GP on 22 November 2016 with a suspected DVT, Mr Dymond, having a Wells score of 2, was assessed as being ‘likely’ to be suffering from a DVT – the investigations included a D-Dimer blood result of 0.97 – and he was discharged home with instructions to self-administer therapeutic LMWH (Clexane) doses at home twice daily in his stomach pending an ultrasound scan booked for 25 November 2016. The scan performed on 25 November 2016 apparently revealed no evidence of a DVT and he was discharged back to the care of his GP. Although the clinical management appeared to conform with the UHCW protocol in place at the time, this protocol did not appear to conform with NICE Guideline 144 (specifically section 1.1.3) which (since 2012) advises a repeat proximal leg vein ultrasound scan 6-8 days later for all patients with a positive D-dimer test and a negative proximal leg ultrasound scan;
(2) Neither the Consultant Orthopaedic Surgeon nor the Anaesthetist performing the operation on 9 March 2017 had been made aware of the DVT investigations/treatment in November 2016;
(3) The DVT investigations/treatment in November 2016 did not appear to feature in the second pre-operative assessment carried out on 12 January 2017.