Mr John Michael James · Prevention of Future Deaths report

On 16 February 2023 I commenced an investigation into the death of Mr John Michael James. The investigation concluded at the end of the inquest on the 6 July 2023. The conclusion of the inquest was a narrative conclusion:

Mr. James died as a result of a pulmonary embolism during the course of a lengthy hospital admission. He was at very high risk of developing a venous thromboembolism. There were three missed doses of anti-coagulation medication in the two weeks leading up to his death.

Mr. James was admitted to Whipps Cross Hospital on the 13 October 2022 and was found to be suffering from malnutrition and a bowel obstruction (later discovered to be due to an adenocarcinoma). He underwent surgery on 18 October 2022 to remove the tumour. This was surgically uneventful. Post-operatively, he required a lengthy period of intensive care. On the 19 December 2022 he was stepped down from intensive care to a ward. He was at a very high risk of developing a thromboembolism due to his cancer diagnosis, recent surgery, lengthy period in hospital and immobility. During the period of 9 to 15 January 2023 he refused his anti-coagulation medication on three occasions. The reason for refusal is unclear and there is no documented evidence that the risk of non-compliance with the medication was explained to him or escalated to the medical team. On the 20 January 2023, Mr. James suffered from an acute deterioration in his health, culminating in a cardiac arrest. He passed away at Whipps Cross Hospital on the 21 January 2023 from pulmonary embolism. The missing doses of anticoagulation during the two weeks leading up to his death is likely to have contributed to a degree, to the development of the pulmonary embolism.

The refusal of anti-coagulation medication was not brought to the attention of medical staff. The administration of anti-coagulation medication to patients like Mr James, is vital for reducing the risk of a venous thrombo-embolism, a potentially life-threatening condition. There is no electronic prompt/alert to highlight to the medical team when prescribed anticoagulation medication is not administered.

The Trust’s internal investigator recognised that a fail-safe should be put in place within the electronic records, to ensure escalation to the medical team where doses of prescribed anti-coagulation are not administered. Such a measure could prevent similar deaths from occurring. It was considered that this measure could assist in preventing future deaths not just locally, but at a wider level.