Michael Christopher Hopkins · Prevention of Future Deaths report

On 14/6/17 I opened an inquest into the death of Michael Christopher Hopkins who, at the date of his death was aged 55 years old. The inquest was resumed and concluded on 24/9/18
I found that the cause of death to be: -
1a. Pulmonary Thromboembolism
1b. Fracture of Right Patella (operated 13/5/17)

I concluded with a narrative conclusion as follows:
On 9/5/17 Michael Christopher Hopkins had an unwitnessed fall in the garden of his home address. When taken to Bradford Royal Infirmary, an x-ray indicated that he had sustained a multi-fragmentary fracture of his right patella, which required surgery to correct on 13/5/17, which went without event, and he was discharged on 16/5/17. Subsequently, on 9/6/17, he collapsed at his home address with difficulties breathing, but notwithstanding the attempts of paramedics to resuscitate him, he died from a pulmonary thromboembolism, a known complication of his surgery of 13/5/17.

At approximately 4.15pm on 9/6/17 Mr Hopkins had an unwitnessed fall in the garden of his home address. When taken to Bradford Royal Infirmary he was found to have sustained a multi fragmentary fracture of his right patella. Surgery to correct it was carried out on 13/5/17 to correct it, which went without event and he was discharged on 16/5/17. Thereafter post operatively Mr Hopkins struggled with his mobility and complained of pain in his lower ankle and upper thigh. Given the severity of the pain Mr Hopkins visited his GP on 8/5/17 since he thought it was an infection of his wound. After examination the GP confirmed that his wound was not infected and it was dressed. The next day of 9/6/17 he suffered his collapse and died at his home address.

To review current practice guidelines with respect to the information provided to patients on discharge from hospital that may be at risk of the formation of thromboembolisms given they have had recent surgery after sustaining a trauma.