Rainer Wickens · Prevention of Future Deaths report

On 17/9/12 Mr Richard Travers Senior Coroner for Surrey, opened an inquest into the death of Rainer Wickens who, at the date of his deaths was aged 59 years. The jury inquest was resumed on 28/4/14 and concluded on 2/5/14
The jury found that the cause of death to be: -
1a. Pulmonary Thrombo-Embolism
1b. Deep Vein Thrombosis
II Fracture of the Thoracic Spine (Operated)
The jury found a narrative conclusion

On the morning of 3/9/12, Mr Wickens fell through the roof of the single storey rear extension to 28 Yew Tree Road, whilst in the process of assisting in its demolition as part of his employment. As a consequence of the fall, paramedics were called and he was taken to St George’s Hospital, where he was found to have sustained a fracture to his thoracic spine. The fracture was stabilised as a result of surgery carried out on 5/9/12. During his admission to hospital there were episodes where his blood oxygen saturations gave cause for concern. During his subsequent post operative intensive care, a decision was made by his treating doctors for tests to exclude the formation of a Pulmonary Embolism. Doctors requested the test on the morning of 6/9/12, the day after his operation, but Mr Wickens suffered a cardiac arrest and died before the tests were made in the late afternoon of the same day.

Although Mr Wickens was at risk of clot formation, he remained untreated for clot formation for 10 hours in A&E
Gaps in the medical notes
Poor verbal communication at handovers between treating doctors
Breakdown in communication between junior doctor and radiologist resulting in avoidable delay of CTPA
Delay in commencement of inquiry of the SUI report and the impact of the delay on remedial action re impact on patient treatment

I would be grateful if you could re consider the appropriateness of allowing such vulnerable and unsupervised residents access to the stairs given the potential for serious injury.