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recurance

Adam Stuyvesant

6 Oct 2023 · Coroner Ian Singleton · Wiltshire and Swindon

The coroner's concerns

  1. 1. restricted calf pump function

    “The wearing of a plastic boot can lead to lower limb immobility and the possibility of a restriction in the "calf pump function" which can lead to deep vein thrombosis”
  2. 2. DVT risk assessment omission

    “The DVT risk assessment in use in the Emergency Department at The Great Western Hospital, made no provision to take account of the immobilisation when considering whether anti-clotting medication should be prescribed”
  3. 3. untreated DVT leading to pulmonary embolus

    “That without taking account of the immobility, as part of the DVT risk assessment, further patients may not be prescribed anti-clotting medication and as a result develop DVT, resulting in death from pulmonary embolus”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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