Susan Lynne EDWARDS · Prevention of Future Deaths report

On 17 October 2023 I commenced an investigation and opened an inquest into the death of Susan Lynne EDWARDS. The investigation concluded at the end of the inquest on 28 May 2024.

The conclusion of the inquest was that Mrs. Edwards “Died as the result of a recognized complication of an accidental fall”.

In answer to the questions “when, where and how did Mrs. Edwards come by her death?”, I recorded as follows:

“On 7.10.23 Susan Edwards, who had fractured her left neck of femur in a fall in hospital in August 2023, and who had been admitted to Worcestershire Royal Hospital on 10.9.23 and treated for a likely urinary tract infection, suffered a sudden deterioration in her condition. Despite treatment, she declined and died in hospital later the same day. Post mortem examination has established that she died as the result of developing a large pulmonary embolus.”

1) On 19 September 2023 a Venous Thromboembolism Risk Assessment made clear that Mrs. Edwards should be provided with mechanical thromboprophylaxis. This instruction was not entered on Mrs. Edwards’ anticoagulation drug card, and Mrs. Edwards was not provided with any form of mechanical thromboprophylaxis between that date and her death 18 days later on 7 October 2023. No nurse or reviewing doctor picked up on this omission.

Although I was satisfied that, in this case, the provision of mechanical thromboprophylaxis would probably not have prevented Mrs. Edwards’ death, I am concerned that:
(a) no system appears to be in place at Worcestershire Royal Hospital to ensure that such an instruction is carried out; and
(b) as long as that remains the case, the lives of patients who require thromboprophylaxis during a hospital admission may be put at risk.