Mrs Jean James · Prevention of Future Deaths report

On 10 January 2014 I commenced an investigation into the death of Mrs James aged 75. The investigation concluded at the end of the inquest on 12 March 2014. The conclusion of the inquest was: -
‘Natural Causes Contributed to by Neglect’

On 24 December 2013 Mrs James was admitted to the Acute Medical Unit from the Emergency Department. The attending doctor was to complete the admission documentation, the electronic venous thromboembolism assessment and the electronic prescription record. This began at 4:50pm and after five interruptions was completed at 6:20pm. The intention was to prescribe prophylactic Dalteparin, but this was not done. Although Mrs James was seen by a number of other doctors, the opportunity to prescribe Dalteparin was not taken. The pharmacy did raise a query about Dalteparin but that did not appear to be communicated so that the problem could be rectified.

Mrs James died on 8th January 2014.

Post Mortem examination has revealed the cause of Mrs James’ death as: -
Ia Bilateral Pulmonary Thromboembolism;
due to
Ib Deep Venous Thrombosis

1) The time taken to complete the initial documentation was longer than it ought to have been given the interruptions to the process.

2) The omission to prescribe prophylactic Dalteparin had not been subject to any effective review by a clinician or a nurse.

3) When the pharmacy raised a query, it was not communicated effectively.

4) Systems, forms, checklists, policies, procedures and protocols and compliance with them may not be sufficiently robust to deal with human factors.

The failures revealed without correction from 24 December until Mrs James’ acute deterioration and death on 8 January 2014.

I heard evidence about the number of initiatives that were under way, including increased vigilance. However, I remain concerned that such steps may be insufficient to effect change in a more timely way.