Adam Stuyvesant
PFD Report
Historic (No Identified Response)
Ref: 2023-0372
Coroner's Concerns (AI summary)
The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not receiving crucial anti-clotting medication and developing fatal pulmonary embolisms.
View full coroner's concerns
(1) 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) 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) 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.
(2) 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) 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.
Sent To
- Great Western Hospital ›The Great Western Hospital
Response Status
Linked responses
0 of 1
56-Day Deadline
5 Dec 2023
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 2 September 2022 I commenced an investigation into the death of Adam Connelly STUYVESANT. The investigation concluded at the end of the inquest on the 6 October 2023. The conclusion of the inquest was: Narrative Conclusion On the 17 August 2022 Adam Connolly Stuyvesant was involved in a minor, single vehicle road traffic collision, on the Marlborough Road at Pewsey Wiltshire. He was admitted to The Great Western Hospital Emergency Department, Marlborough Road, Swindon, where in addition to minor injuries he was diagnosed with an avulsion fracture from the lateral malleolus in the left ankle. Adam was given a plastic boot to wear which immobilized the ankle. At that time, the DVT risk assessment had it been carried out would only have taken account of Adam's size, not the ankle immobility, which carried a risk of deep vein thrombosis. On the 22 August 2022 Adam collapsed at Unit 31 Blackworth Industrial Estate, Highworth, Swindon and despite best efforts at resuscitation, died. The post mortem confirmed that death was due to the immobilisation of the left ankle allowing a deep vein thrombosis to develop which led to pulmonary embolus. la Pulmonary Embolus lb Deep Vein Thrombosis le Lower Limb Immobilisation Secondary to Injury after Road Traffic Accident II
Circumstances of the Death
See Box 3 above
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.