Margaret HEAL · Prevention of Future Deaths report

On 25/07/2022 14:17an investigation was commenced into the death of Margaret HEAL on 30/07/1935 00:00. The investigation concluded at the end of the inquest on 06/12/2023 00:00. The conclusion of the inquest was that Margaret Heal died on 12th July at her home, ████████, from a massive pulmonary thromboembolism which had caused by a deep venous thrombosis. This is a natural disease running its full course and resulting in her death. She had stopped taking her anti-coagulant medication on medical advice 10 days prior to her death to undergo surgery. She did not resume this medication after it. It is unclear on the evidence if she was unaware of the need to resume the medication or she chose not to resume the medication..

Margaret Heal died on 12th July at her home, ████████ from a massive pulmonary thromboembolism which had caused by a deep venous thrombosis. This is a natural disease running its full course and resulting in her death. She had stopped taking her anti-coagulant medication on medical advice 10 days prior to her death to undergo surgery. She did not resume this medication after it. It is unclear on the evidence if she was unaware of the need to resume the medication or she chose not to resume the medication.

During the course of the inquest it became apparent there was no evidence to show the deceased had been provided with a document instructing her to resume her anti coagulation. Whilst this requirement is set out in the Trust's procedures, no evidence was found it had taken place. No document was found in Mrs Heal's home at the time of her death. It is of concern that Mrs Heal was an 86 year old lady living alone after her discharge from hospital. Is there more that can be done to ensure patients particularly who are vulnerable and / or elderly are given advice regarding medication and drugs in a manner, to ensure as far possible, they are aware of the need to recommence their medication.