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Investigation and inquest
An inquest into the death of Peter James Michael Unsworth was opened on the 9th August 2018 and resumed on the 21st October 2020. The inquest concluded on 2nd November 2020. I concluded that the medical cause of his death was;
1a Pulmonary Thrombo-Embolism
1b Deep Vein Thrombosis
I concluded with a narrative conclusion:
Peter James Michael Unsworth had developed deep vein thromboses twice and was on long term anticoagulant medication prior to having a right hip replacement operation in April 2018. On the 23rd May 2018 he was admitted to hospital as an emergency. He was found to have developed a further deep vein thrombosis and his right hip was severely infected. Administration of anticoagulation medication was a significant factor in the development of the infection. He required a lifesaving operation to washout the infected hip prior to which an IVC filter was implanted to prevent pulmonary emboli. Thereafter he underwent the first stage of revision surgery. He remained treated on a therapeutic dose of Clexane post operatively. Haematological advice was sought as to whether the dose of Clexane could be reduced to prevent a further infection developing in the right hip. No note was made of the advice given. The orthopaedic surgeon with responsibility for his care understood that he could reduce the Clexane dose to a prophylactic dose if, in his clinical judgment, this was necessary to prevent a further hip infection. He reduced the dose of Clexane to a prophylactic dose. As a consequence of reduced anticoagulation Peter Unsworth developed pulmonary emboli which totally occluded his pulmonary arteries. He died at home at ████████, Shepperton on the 29th July 2018.
Circumstances of the death
The circumstances of the death are detailed in the narrative conclusion.
Coroner’s concerns
The evidence showed that:
1. The advice provided by the Consultant Haematologist related to a very complex medical situation. It was not recorded in writing. The Consultant Orthopaedic surgeon did not record it in the patient’s records nor email his understanding of the advice to the Consultant Haematologist for confirmation of what he understood the advice to be.
2. The Consultant Haematologist did not confirm her advice in writing or make any record of the advice given.
3. As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the advice.
Information checked against the published report and official responses