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Investigation and inquest
On 03 October 2023 I commenced an investigation into the death of Roger Knight SMITH aged 80.
The investigation concluded at the end of the inquest on 29 January 2026.
The conclusion of the inquest was:
Narrative Conclusion - Roger Knight SMITH was a much loved and desperately missed member of his Family. He was a man who had a great zest for life, described by his family as amazing, exceptionally intelligent, creative, kind, adventurous and funny. A person who during his life had a significant, positive impact on the lives of those around him.
Mr. SMITH’s previous medical history included a diagnosis of cerebral amyloid angiopathy (CAA) following a stroke in 2012. He suffered a further stroke in 2016 which resulted in hospitalisation and from which he made a good recovery.
Due to his diagnosis of and treatment for cerebral amyloid angiopathy, Mr. SMITH suffered from an increased risk of suffering from strokes. As a consequence, Mr. SMITH presented as a patient with complex considerations for his clinical care and management.
Mr Smith was admitted to West Suffolk Hospital on 14th April 2023 with confusion, hallucinations and generalised weakness. He was treated with antibiotics for a clinical differential diagnosis of infection of uncertain origin. On 28th April he was commenced on steroids for a possible alternative diagnosis of vasculitis. On 1st May he developed slurred speech. A computed tomography (CT) head scan showed new multiple left intracerebral haemorrhages. He was subsequently transferred to the stroke unit where he received treatment in relation to his stroke. He subsequently developed a Clostridium Difficile (C Diff) infection and received treatment in relation to this.
The speed of Mr. SMITH’s recovery was adversely affected by the fact that he was unable to engage effectively with the physiotherapy treatment offered. This was because of the inappropriate prescription and administration of baclofen over the period 27th June to the 24th July 2023. Mr. SMITH was discharged on the 21st August 2023 having been assessed as medically fit for discharge.
Mr Smith was readmitted to West Suffolk Hospital on 25th August 2023 with increased bowel motion frequency and drowsiness. A diagnosis of recurrent C. Diff infection was made and treatment for this condition commenced. He was also commenced on low dose tinzaparin for venous thromboembolism (VTE) prophylaxis on the 26th August 2023.
Correspondence from treating neurologists at another hospital that formed part of Mr. SMITH’s medical records and which advised against this prescription of anti-coagulation therapy was not followed. Mr. SMITH declined tinzaparin administration on the 27th and 28th August 2023. This did not prompt a discussion between clinicians and either Mr. SMITH or his family as to the reason why he had declined. Nor were alternative forms of management of the VTE risk discussed as had been the case during the 14th April to 21st August 2023 West Suffolk Hospital admission. Seven further doses of tinzaparin were administered to Mr. SMITH over the period 29th August to the 4th September 2023.
On 4th September 2023 Mr. SMITH developed a fever, tachycardia, tachypnoea and reduced consciousness level. He was treated for aspiration pneumonia and sepsis. A CT head scan on 5th September 2023 showed a new large right cerebral haemorrhage with intraventricular extension. A repeat CT head scan on 7th September 2023 showed an increase in the haemorrhage size and mass effect with midline shift. A palliative care referral was made. Treatment with antibiotics for pneumonia and C Diff. continued. Sadly Mr SMITH deteriorated further and died on 12th September 2023.
A postmortem examination of Mr. SMITH’s body established that his medical cause of death was due to Bronchopneumonia arising from immobility due to the effects of the stroke he had suffered on the 4th September 2023.
Roger Knight SMITH died due to the effects of suffering a stroke brought about by the administration of tinzaparin over the period 21st August – 4th September 2023.
The medical cause of death was confirmed as:
1a Bilateral Bronchopneumonia
1b Immobility
1c Recurring Intracranial Haemorrhages
2 Cerebral Amyloid Angiopathy, Hypertension, Clostridium Difficile Infection and Coronary Arteries Atherosclerosis
Circumstances of the death
Narrative Conclusion see part 4.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
Important information relating to advice concerning the prescription of anti-coagulation therapy (low weight molecular heparin - LWMH) for venous thromboembolism (VTE) prophylaxis and which was contained in Mr. Smith’s medical records, was not flagged for clinician attention as part of the electronic records management system in use at West Suffolk Hospital. This meant that when Mr. Smith was readmitted on the 25th August 2023, this information did not form part of the reviewing consultants considerations and would not be thought to precribe tinzaparin (LWMH) to Mr. Smith for VTE prophylaxis. He subsequently received 8 doses of tinzaparin which contributed to him suffering a catastrophic stroke that led to his death.
During both admissions to West Suffolk Hospital during the period April to August 2023, Mr. Smith and his Family fiercely advocated for considerations associated with his cerebral amyloid angiopathy (CAA) to be taken into account as part of his care and treatment. This occurred during Mr. Smith’s first admission between 14th April and 21st August 2023 with alternative management used to address the VTE risk. This did not occur during Mr. Smith’s second admission from 25th August 2023 and despite Mr. Smith declining tinzaparin on two occasions, the medication continued to be administered without adequate consideration as to why Mr. Smith had declined it or by engaging in consultation with either Mr. Smith or his Family.
There was limited input from the West Suffolk Hospital stroke team into Mr. Smith’s care and treatment during the period following his admission on the 14th April 2023 until his stroke on the 1st May 2023. This was notwithstanding Mr. Smith and his Family raising on multiple occasions the increased risk of stroke to Mr. Smith due to his pre-existing CAA condition. Following his stroke on the 1st May 2023, measures taken to diagnose the stroke, move Mr. Smith to a stroke unit and correctly manage his blood pressure in accordance with NICE guidelines were slow, and with respect to blood pressure management, non-concordant with existing national stroke guidance.
I am concerned that the West Suffolk Hospital patient records management system is ineffective in accurately highlighting important information which should inform patient care and treatment.
I am concerned that communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment.
I am concerned that effective procedures are not in place at West Suffolk Hospital to deliver timely specialist stroke team input for the purposes of managing stroke risk as part of a multi-disciplinary team approach for patients admitted with conditions that expose them to higher risk of VTE (e.g. CAA).
