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Investigation and inquest
On 26th November 2013, I commenced an Investigation into the death of Carol Lynne Walker, aged sixty-eight years. The Investigation concluded at the end of the Inquest on 18th July 2014. The conclusion of the Inquest was Carol Lynne Walker had suffered a fall causing a hairline fracture of her left ankle and for a plastercast to be applied. Mrs Walker’s death was confirmed at her home address, 3 Avon Court, Leeds at 0958 hours on 19th November 2013 as a consequence of her developing a pulmonary thromboembolism because of deep vein thrombosis of the left leg which was a complication of her left ankle fracture. A short form conclusion of accidental death was recorded.
Circumstances of the death
1. Carol Lynne Walker fractured her ankle on 25th September 2013. Mrs Walker was taken by a relative to Harrogate District Hospital on Friday, 25th October 2013 where an x-ray examination revealed that she had suffered a hairline fracture to her left ankle.
2. This was treated by a back slab plastercast. Mrs Walker was discharged after fracture clinic follow-up had been arranged.
3. Mrs Walker was mobilising quite well on hand crutches and was receiving daily help and support from her family.
4. It transpired from Mrs Walker’s previous medical history that she had suffered a pulmonary embolism. It is not clear whether this was communicated to those treating Mrs Walker at the hospital but there was no record made of this.
5. On Monday, 18th November 2013, Mrs Walker informed her family that she was well and that there was no need to visit. At 0930 hours on Tuesday, 19th November 2013 she was discovered by her daughter-in-law in a collapsed state. Paramedics attended who confirmed her death at 0958 hours on 19th November 2013.
6. A Coroner’s Post Mortem examination reveals the cause of death to be 1(a) Pulmonary thromboembolism due to (b) deep vein thrombosis of left leg due to (c) left ankle fracture.
Coroner’s concerns
1. I understand that at the time it was not standard practice in either the Orthopaedic Department or the Emergency Department at Harrogate District Hospital to routinely administer Chemical Thrombo Prophylaxis to patients with conservatively treated lower limb injuries immobilising cast considered to be at low risk of venous thromboembolism.
2. Nor was it standard practice in the Trust for a formal venous thromboembolism risk assessment to be undertaken in this patient group.
Information checked against the published report and official responses