Brian BEER · Prevention of Future Deaths report

On 13 March 2024 I commenced an investigation into the death of Brian BEER aged 86. The investigation concluded at the end of the inquest on 06 September 2024. The conclusion of the inquest was that:

Narrative Conclusion - Brian Beer, an 86 year old gentleman, died due to a recognised complication of necessary surgery on a fractured hip sustained in an unwitnessed fall. The development of this complication was contributed to by the fact that local guidelines were followed as to the cessation of prophylactic anti-coagulants after surgery, whereas evolving international policy indicates that prophylaxis should be continued for a longer time period. The death was also contributed to by frailty and advanced dementia, which both contributed to the fall and compromised Mr Beer’s physiological reserve, such that his capacity to recover from fracture, surgery and serious illness was compromised.

The medical cause of death was confirmed as:

1a Small Bowel Ischaemia
1b Superior Mesenteric Artery Thrombus
1c

2 Advanced Dementia, Left Hip Hemiarthroplasty 08.01.24 with VTE Prophylaxis for 28 Days

Brian Beer died peacefully at the West Suffolk Hospital on 1 March 2024. He died of small bowel ischaemia, suffered due to a blood clot in an artery that provides blood to the small bowel. Sustaining such a blood clot is a recognised complication of surgery on a hip fracture. Mr Beer underwent a left femur head replacement on 8 January 2024, owing to a hip fracture. This fracture was sustained in an unwitnessed fall at his care home, which was contributed to by advanced dementia and frailty.
Although Mr Beer received prophylactic anti-coagulation after the hip surgery, in accordance with and for the duration required by local hospital guidelines, the international policy in this regard is evolving such that patients may be given anti-coagulation after surgery for a longer period of time. The cessation of anti-coagulation in Mr Beer’s case at the time it was ceased contributed to his death.

If NICE guidelines as to prophylactic anti-coagulation after surgery on a hip fracture do not reflect the most up-to-date international learning, then there is a risk of future deaths being contributed to by hospitals following NICE guidelines when a longer period of anti-coagulation post-surgery would better protect them against recognised complications of the surgery.

Explanation:

On referral of the case to the Coroner's Court: ████████, Medical Examiner, wrote:

"Given that he had no history of atrial fibrillation, ischaemic heart disease, peripheral vascular disease or diabetes and atherosclerosis was not noted on the CT scan, there appears to be a temporal relationship between the discontinuation of the Tinzaparin and the superior mesenteric arterial thrombus causing the ischaemic bowel. Local policy was followed. Internationally the policy is evolving ... patients have longer on anti-coagulant after fractured neck of femur. Referral in light of a potential indirect link between the discontinuation of the anticoagulation and the death."

In further communication with the Court in the course of the investigation, ████████ wrote:

"His death is directly related to the thrombus within the superior mesenteric artery and his only other co-morbidity is advanced dementia and frailty. It is likely that if recommendations for fracture neck of femur is brought into line with the recommendations for elective hip replacement surgery, he would not have had this thrombus. Therefore, to the best of my knowledge, the cessation of the anti-coagulation did make a material difference to his death."

The findings and conclusion of the Inquest were based on this evidence.

After the conclusion of the Inquest, I received further communication from ████████. In that further clarification, she stated that "venous thromboprophylaxis ('VTE') prophylaxis ... was for the prevention of venous thrombosis and this gentleman died of an arterial thrombus, therefore it is not clear what role the VTE prophylaxis plays in this, however there is potentially a state of hypercoagulability following discontinuation of VTE prophylaxis." ████████ went on to add that "our local guidelines are in line with NICE guidelines"; but she queried "whether the NICE guidelines (now 5 years old) need to acknowledge this potential risk of hypercoagulability in the immobile, elderly patients on discontinuation of the VTE prophylaxis and/or consideration of alternative agents or regimes in this particular demographic, should it become evident that there is indeed this risk."

After the conclusion of the Inquest, I was also provided with an opinion from ████████, an expert haematologist. ████████ advised that the guidance relating to venous thrombosis is not relevant to an arterial clot - and prophylaxis is not given against arterial clots. In her view, and that of two other expert practitioners in this area, the cessation of VTE prophylaxis and the development of the arterial clot were not related. ████████ added that neither she, nor her two colleagues, are aware of an evolving international consensus over the length of time for prophylaxis after a fractured neck of femur.

A communication was also then received from ████████ who added: "The Hip fracture team are aware of some emerging early evidence regarding extending VTE prophylaxis in such patients beyond the 4 week point."

Bearing in mind ████████ evidence regarding evolving international policy, and ████████'s indication of "some emerging early evidence" in this regard, in my opinion it is appropriate to ensure that this concern is brought to the attention of NICE, to ensure that appropriate consideration be given as to whether the national guidelines in this area require revision, particularly bearing in mind that surgery on hip fractures is far from uncommon in immobile and elderly, and therefore vulnerable, patients.