Elizabeth Jayne Cooper · Prevention of Future Deaths report

On the 16th September 2013 I commenced an investigation into the death of Elizabeth Jayne Cooper who was born on the 2nd Nov 1980. The investigation concluded at the end of the inquest on 23rd April 2014. The conclusion of the inquest was that Elizabeth died of 1a Pulmonary Thromboembolism 1b Deep Vein Thrombosis right lower limb 1c Hypercoagulable state due to Factor V Leiden mutation. I gave a conclusion of natural causes.

Elizabeth had been diagnosed with the genetic condition referred to in 1c above in 2011. This followed a diagnosis of a DVT and possible pulmonary embolism. Elizabeth was clinically obese and suffered from diabetes. She was thereafter given conflicting advice on the precautions she should take if she travelled by air. One specialist advised her to take anticoagulant prophylaxes but her GP did not consider this to be necessary. She died immediately following a holiday to Tenerife involving air travel. No causal connection was made in the inquest between the flights and her death but it became clear from the evidence that although she was aware of the risks created by the condition and other risk factors she seemed not to be aware of the consequences of taking any of those risks of which flying was one. Her actions on becoming ill on holiday support this conclusion. The literature from her specialist did not give any warnings in this regard. The guidelines produced to the inquest highlight the statistical increase of risks but not the consequences of an untreated DVT. Her sister who gave evidence, although not carrying the genetic condition, had previously suffered a DVT and was similarly not aware of the fatal consequences of an untreated DVT. Further her family had not been made aware of the option to be tested for the genetic condition to enable them to properly consider their own health requirements.

(1) Advice on precautions to be taken for those persons with the genetic condition is unclear especially concerning air and long distance travel.

(2) There seems no clear pathway for information concerning the condition to be passed to members of the family of the patient for them to assess their own position.

(3) No information leaflet

(a) was available to Elizabeth concerning the fatal consequences of not seeking medical assistance;
(b) was available to be given to members of Elizabeth’s family to inform them of the risks involved in Factor V Leiden Mutation and the options open to them.