Ernest Smith · Prevention of Future Deaths report

On 20 April 2023 an investigation was commenced into the death of Ernest Smith, aged 77 years. Ernest Smith died on 10 April 2023. The investigation concluded at the inquest on 26 February 2024. The conclusion of the inquest was narrative: Mr Smith developed left leg haematoma secondary to prophylactic anticoagulation for venous thromboembolism. Mr Smith developed septic infection that did not respond to treatment.

With a medical cause of death of 1a Sepsis 1b Hospital Acquired Pneumonia and Infected Haematoma 1c Haematoma Secondary to Anticoagulation, 2 Type II Diabetes Mellitus, Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease

Ernest Smith died at the Princess Alexandra Hospital on 10 April 2023 due to Sepsis due to Hospital Acquired Pneumonia and Infected Haematoma. The Haematoma was secondary to Anticoagulation in a background of Type II Diabetes Mellitus, Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease. Mr Smith was admitted to hospital on 22 February 2023 unwell. Mr Smith received prophylactic anticoagulation to prevent blood clots and was noted to have stripe type bruising on his lower limbs on 10 March and required a medical review that was undertaken on the evening of 12 March and the anticoagulation was stopped on 13th March following the development of a left leg haematoma requiring surgical evacuation and debridement. Mr Smith was discharged for rehabilitation on 17 March and readmitted on 23 March with bleeding from the haematoma. Mr Smith was noted to have purulent infection on 30 March and the surgical team awaited advice from Broomfield Hospital. Antibiotics were commenced on 3 April and Mr Smith was septic on 4 April and underwent debridement of his haematoma on 5 April. Mr Smith continued on antibiotic therapy on the advice of microbiology and developed pneumonia, he deteriorated over 9th April and 10 April.

a. Medical review requested on 10 March by nurses due to concerns about the acute development of bilateral bruising on Mr Smith's legs. This request was chased by nurses on 11 March and was not conducted until the evening of 12 March.
b. A further medical review was conducted in the early hours of 13 March as Mr Smith was in pain and had developed a leg haematoma.
c. It took 3 days for consultant review of Mr Smith. On 13 March Mr Smith was reviewed by a consultant from another ward and prophylactic anticoagulation was discontinued.
d. Mr Smith was medically reviewed and considered fit for discharge on 30 March. A tissue viability nurse review that day noted an infected leg haematoma and recommended a surgical referral for consideration of washout and debridement.
e. Antibiotics for the infected haematoma were not commenced until 3 April.
f. Sepsis was highlighted by the Trust surgical team on 3 April and the Sepsis Protocol was not followed.