Stephen John Bird · Prevention of Future Deaths report

On 16th May 2016 I commenced an investigation into the death of Stephen John Bird, aged 51. The investigation concluded at the end of the inquest on 21st July 2016.

The medical cause of death was recorded as:-
1a Pulmonary Embolism
1b Deep Vein Thrombosis
1c Recent Surgery for Achilles Tendon Injury

The narrative conclusion recorded was as follows:-
Mr Bird underwent surgery at the Shelbourne Hospital on 6th May 2016. Prior to the procedure he had been assessed as being at a high risk of Venous Thromboembolism (VTE) and this was recorded in the medical notes. Mr Bird was re-assessed subsequently and considered to be a low risk of VTE. Pharmacological VTE prophylaxis was not prescribed. A mechanical VTE prophylaxis regime was prescribed. Mr Bird died at his home address during the afternoon of 11th May 2016. Mr Bird’s death resulted from a risk of the surgical procedure.

Mr Bird had an elective operation on the 6th May 2016 at the Shelbourne BMI hospital High Wycombe for an achilles tendon injury. The procedure appeared to go well and he was discharged the same day with Codeine as pain killers and thrombo embolus deterrent stockings.
On the 11th May 2016 Mr Bird’s partner left the house approximately 0800hrs. She spoke with Mr Bird at midday and all appeared normal. He was found at 1830hrs by the partner’s daughter collapsed unresponsive on the floor next to his bed at his home address.
Paramedics attended but Mr Bird was declared deceased at his home address.
He was taken to Wycombe Park Hospital where a post mortem examination was carried out and the prescribed medical cause of death identified. Further investigations with the Shelburne revealed that Mr Bird was not prescribed anti-coagulation but was given an exercise regime upon discharge. The key facts established during the Inquest were recorded in a brief, neutral narrative conclusion.

(1) The patient records, the documentation of consultations, clinical decisions, changes to previous assessment decisions and the discharge records were incomplete, inconsistent and/or conflicting and this was acknowledged during the Inquest hearing.

(2) Evidence given regarding the investigation by the hospital into Mr Bird’s death and the preparation of a draft Significant Clinical Incident Investigation (SCII) Report (disclosed as part of the Inquest process) identified an assumption of facts within that draft report which conflicted with documentary records and this was acknowledged during the Inquest hearing. It was indicated during the hearing that the hospital places reliance upon SCII reports as part of a learning process.