UK Inquiry Tracker

Mark Holden

PFD Report Historic (No Identified Response) Ref: 2021-0294

Date of Report 6 September 2021

Coroner Alison Mutch

Coroner Area Greater Manchester South

Response Deadline est. 1 November 2021

Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

A telephone-only GP consultation missed DVT, an abnormally high D-Dimmer failed to alert on the electronic system, and national guidance lacks COVID-19 specific clot risk management.

View full coroner's concerns

1. The appointment with the GP was via telephone due to Covid. As a result, there was no examination of Mr Holden and no opportunity to identify the DVT which was present at the time of the telephone consultation.

2. The D-Dimmer of over 10,000 did not trigger an alert on the Lorenzo electronic system due to how it was reported and the configuration of Lorenzo at that time at the Trust. The Trust have taken steps to change how the reports are input into Lorenzo to ensure a raised D-Dimmer such as this triggers an alert. It was unclear if that learning has been shared across the NHS to other trusts who use Lorenzo to ensure that alerts are triggered.

3. The inquest heard that there will often be a raised D-Dimmer with Covid-19 and that in addition that there is an increased risk of clots with Covid-19. The evidence before the inquest was that the existing NICE guidance used by clinicians does not deal with the Covid-19 aspects/ recognised risks.

Sent To

Department of Health and Social Care
NHS England

Response Status

Linked responses 0 of 2

56-Day Deadline 1 Nov 2021

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 3rd March 2021 I commenced an investigation into the death of Mark Holden. The investigation concluded on the 24th August 2021 and the conclusion was one of Narrative: Died from the complications of a deep vein thrombosis not diagnosed until after death and that was probably present on 19th February 2021 and on 23rd February 2021 when medical advice was sought. The medical cause of death was 1a Pulmonary Embolus 1b Deep Vein Thrombosis, II Covid -19 Pneumonia

Circumstances of the Death

Mark Thomas Holden was diagnosed with Covid-19 on 18th February 2021 having had symptoms for a few days previously. He attended the Emergency Department at Tameside General Hospital. His D-Dimer was 1505. He was discharged home with advice to return if he deteriorated. On 19th February 2021, he returned to Emergency Department at Tameside General Hospital concerned that he had a deep vein thrombosis in his left leg. His D-Dimer was over 10,000. The treating clinician did not see the report for reasons that were unclear. He was referred for a doppler scan. The scan looked at the superficial femoral junction and not the calf. Under NICE guidance a follow up appointment should have been made given the raised D-Dimer. One was not made. The discharge summary did not contain the D-Dimer reading. He was not given anticoagulants. On 23rd he contacted his GP still feeling unwell. A telephone appointment was conducted. The GP was unaware he had a raised D-Dimer. Amoxicillin was prescribed for a persistent cough. No face to face examination took place. A DVT was not considered. On 26th February 2021, he collapsed at home. He was taken to Tameside General Hospital where attempts to resuscitate him were unsuccessful. Post-mortem examination found that he had a deep vein thrombosis in his left calf that had been there for about 7-10 days and that had led to a pulmonary embolus.