Jonathan Mark Kingsman · Prevention of Future Deaths report

On 13.03.20 I commenced an Investigation into the death of Jonathan Mark Kingsman, aged 47 years. The Investigation concluded at the end of the Inquest on 12.07.21. The conclusion of the Inquest was that death was as a result of ‘Natural Causes’,

The medical cause of death being recorded as:

1a Pulmonary Thromboembolism;
1b Deep Vein Thrombosis;

Mr Kingsman was admitted to Fulbourn Hospital, Cambridge under s2 of the Mental Health Act 1983 on 26.01.21 where he remained until his death on 01.02.20. On admission it was reported that Mr Kingsman had not consumed any fluids for at least several hours.

The Doctor on call carried out an initial risk assessment using the Department of Health Template titled ‘Risk Assessment for Venous Thromboembolism(VTE)’ Gateway reference no: 10278. At ‘Step 1’ the document requires an assessment of the patient’s anticipated mobility. Where the patient is ‘NOT expected to have significantly reduced mobility relative to normal state’ the assessor is directed to terminate the assessment. It was agreed evidence at the Inquest that Mr Kingsman fell into this category and likewise agreed that throughout his time in hospital that there were no changes to his mobility which would have prompted a renewed risk assessment.

The Inquest also heard evidence that ‘immobility’ was one of a number of potential risk factors for VTE. These included:- obesity; inherited blood clotting disorder; smoking; personal or family history of DVT or PE; dehydration; receipt of certain psychiatric medication(there are others listed on the risk assessment form itself). At least some of these potential risk factors may have been present in this case although on the evidence presented it was not possible to conclude to the required standard which, if any, may have played a part in Mr Kingsman’s death. None of these risk factors was considered as part of the risk assessment process as Mr Kingsman did not get past ‘Step 1’ referred to above. Additional risk factors including those identified above are only considered at ‘Step 2’ in the risk assessment process. The evidence was that at no stage during his hospital admission was Mr Kingsman ‘expected to have significantly reduced mobility relative to normal state’ and therefore there was no stage at which these risk factors were prompted for consideration at ‘Step 2’ in the risk assessment process. Despite this Mr Kingsman died as a direct result of a pulmonary thromboembolism caused by deep vein thrombosis.

The Inquest was also advised that the risk assessment form contains no guidance on its completion and no definitions of some of the terms used ‘eg ‘significantly reduced mobility compared to normal state’;

That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased mobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future;

The risk assessment form contains no guidance on its completion and no definition of certain terms.