Mrs Vivien Brunning · Prevention of Future Deaths report

On 27th July 2020 I commenced an investigation into the death of Mrs Vivien Brunning, aged 87 years. The investigation concluded at the end of the inquest on 7th October 2021. The conclusion of the inquest was that Mrs Brunning died from;

1a Right Basal Ganglia and Occipital Lobe Ischaemic Strokes

1b Atheromatous thromboembolism during attempted thrombolysis for right brachial artery thrombosis

1c Urosepsis and urinary tract obstruction (treated); systemic atheromatosis, hypercoagulability (omission of clexane therapy)

II Diabetes Mellitus; atrial fibrillation A short form conclusion of accidental death was arrived at.

A narrative conclusion was arrived at.

On 9th July 2020 Mrs Vivien Brunning was admitted to hospital with sepsis. Mrs Brunning had been treated in the community with anti-coagulants for atrial fibrillation. In hospital, a venous thromboembolism ("VTE") assessment indicated that Mrs Brunning required prophylaxis to mitigate the risk of developing deep vein thrombosis as an inpatient, she was prescribed low molecular weight heparin ("Clexane").

Mrs Brunning was diagnosed with a kidney stone and underwent a nephrostomy to treat the source of her infection. As a precaution, clexane was held, temporarily, to mitigate the risk of bleeding in the procedure.

Following the procedure, clexane was to be resumed and was administered on 12th July 2020.

On 13 & 14th July 2020 clexane was not administered to Mrs Brunning, in error.
On 15th July 2020 Mrs Brunning was diagnosed with a thrombosis in her right brachial artery, a causal factor in the formation of the clot were the two missed doses of clexane. Mrs Brunning underwent an emergency thrombolysis procedure to dissolve the clot, during the procedure she suffered a stroke due to a recognised complication of the essential, emergency procedure.

Mrs Brunning died on 25th July 2020 due to the effects of the stroke.

1. The hospital notes demonstrate that required venous thromboembolism reviews at 24 & 72 hrs following admission were not undertaken.
2. Prescribed daily injections of low molecular weight heparin were omitted on 13th and 14th July 2020
3. The initial omission on 13th July 2020 was noticed by a ward doctor but was not reported through the Trust’s incident reporting system.