David John Lewsey · Prevention of Future Deaths report

On 21/11/23, I concluded an inquest into the death of David John Lewsey who died on 15/12/22 at the age of 68.
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The medical cause of death was recorded as:
1a) Pulmonary thromboembolism
1b) Deep vein thrombosis of left calf
1c) Knee replacement operation

I recorded a Narrative Conclusion that Mr Lewsey died from a known complication of an elective surgical procedure.

Mr Lewsey was a 68-year-old man who underwent a left knee replacement on 29/11/22. Upon discharge, he was prescribed with two weeks of aspirin to reduce the risk of developing a clot and codeine for pain relief. The codeine caused Mr Lewsey to become constipated.

On 15/12/22, he rang the surgery for treatment to relieve his constipation. In the first call with reception staff, he reported a ‘terrible, terrible pain in his side.’ This information was not passed on to the Advanced Nurse Practitioner (ANP) who returned Mr Lewsey’s call.

In his first call with the ANP, Mr Lewsey said that his left side hurt like he had a stitch and that he felt pain when he breathed in. I found as fact that it was more likely than not that this was caused by a developing pulmonary embolus.

No consideration was given to excluding a PE as a possible cause of the pain. It is more likely than not that the PE was caused by a DVT in his leg that developed following Mr Lewsey’s immobility after his knee operation. Mr Lewsey collapsed later that evening at his home address and could not be resuscitated.

- Evidence was heard at inquest that if the concern of a terrible pain in his side, reported in Mr Lewsy’s first telephone call to reception staff, had been passed on to the ANP, the initial discussion between Mr Lewsey and the ANP may have started down a different path. It was recognised that the doctors and nurses dealing with duty calls work under pressure, and it was felt that ensuring accurate and complete information was passed to them may reduce that pressure and facilitate the provision of a better service to patients.
- The inquest also heard that reception staff had some training to raise a red flag if pain in the ‘chest’ was reported to them. Mr Lewsey said he had pain in his ‘side’ but the precise location of that pain was not explored further. While it was said in evidence that, typically, a PE will present with pleuritic or chest pain, it was noted that NICE guidance includes abdomen pain. You may wish to reflect on whether additional training is required for all staff on how to manage complaints of pain in the chest or abdomen particularly in patients who have recently undergone procedures that may have left them relatively immobile and at an increased risk of developing a DVT.