NICOLA ANNE TWEEDY · Prevention of Future Deaths report

On 31 March 2014 I commenced an investigation into the death of NICOLA ANNE TWEEDY, aged 54 YEARS. The investigation concluded at the end of the inquest on 3 MARCH 2015. The conclusion of the inquest was medical cause of death: 1a) Pulmonary Embolism b) recent varicose vein surgery and narrative conclusion: Mrs Tweedy died following a rare but recognised risk of appropriate surgery.

Mrs Tweedy was admitted to NNUH for elective varicose vein surgery as a Day Case patient on 27 March 2014, having seen the Consultant Surgeon on 26 November 2013 and had a pre-operation assessment on 18 March 2014. There was no evidence that Mrs Tweedy had been handed leaflets regarding the procedure and its risks. The Risk Assessment form for Thromboprophylaxis was not completed as indicated at this time. Despite this being noted immediately prior to the procedure, the Risk Assessment form was never completed. Mrs Tweedy was administered a single dose of prophylaxis. Following review of data and procedures, NNUH have noted that varicose vein surgery does show an increased risk of DVT relative to other Day Case procedures. It has now been decided to routinely prescribe 5 days of thromboprophylaxis to all patients undergoing varicose vein surgery unless there are contra-indications. Following the procedure Mrs Tweedy was taken to the Recovery Ward where she was deemed appropriate for Nurse led discharge. Notes were made by a Nurse recording she had passed urine and eaten supper. Before discharge, a Patient is required to be shown to have eaten and had a drink, passed urine, is able to get up and walk, not feel nauseous, had adequate pain relief and understood instructions for care following discharge. A checklist form for completion on discharge had not been completed. ████████ raised concerns that his wife was not fit for discharge with a Nurse (it may well have been to a different Nurse) in that she had only walked 10 – 15 paces and left in a wheelchair. On 29 March 2014, Mrs Tweedy was found collapsed and died at her home.

(1): Specific leaflets relating to the procedure and aftercare were not handed to the patient. It is understood a “tick box” has now been added to documentation recording that this is done. This will only work if forms are properly and timely completed – see below. It is understood training and auditing of forms is now in place, but it is not clear how this is being carried out.
(2) The Thromboprophylax Risk Assessment form was not completed at any point throughout Mrs Tweedy’s dealings with the hospital. Had the Risk Assessment been completed this would have flagged up specific risk factors relating to Mrs Tweedy well before the operation. It was noted the Risk Assessment had not been completed following Mrs Tweedy being anaesthetised and this did start discussion between the Consultant Surgeon overseeing the procedure and the Anaesthetist about the risk factors and action to be taken. However, at this stage in the procedure, it did not allow for a full and proper consideration of the relevant information early on when proper thought could have been given to the risks and potential risks.
(3) Nursing notes on discharge did not fully cover all the factors required to be checked before a patient is discharged.
(4) There was no evidence that the Nurse completing the notes had actually seen Mrs Tweedy prior to discharge.
(5) The checklist form for completion on discharge was not completed.