On 23rd March 2016 the Senior Coroner, David Horsley, commenced an investigation into the death of Mr Scott Douglas Hooper aged 46 years old. The investigation concluded at the end of the inquest on 17 March 2017 . A Narrative Conclusion was recorded by the jury as follows: Scott Douglas Hooper died as a result of an unexpected but recognised complication of the severity of his pelvic injuries_ The medical cause of death was: 1a) Pulmonary Embolism; 1b) Deep Vein Thrombosis; Ic) Immobility due to fractured pelvis.

Mr Hooper was admitted to Queen Alexandra Hospital in Portsmouth at 08.57 on Saturday 12 March 2016 following an unwitnessed accident at work: He worked as a fork lift truck (FLT) driver at a timber yard: When setting down a double load of hardwood that exceeded the permitted weight for the FLT, the vehicle started to tilt and shed its load. Mr Hooper jumped from the cab at its highest point onto the concrete road: It is believed the FLT then hit him; There were no witnesses t0 the accident but other workers heard a loud crash outside the shed and ran t0 help Mr Hooper: On admission he was triaged and his general observations were normal with little indication of a major injury. By 12.08 he was still not able to be mobilised and his pain level had risen to on a scale of 7-10. An X-ray was ordered at 12.08 and revealed complex pelvic fractures which required a transfer to Southampton General Hospital (SGH)for_surgery Mr Hooper left Portsmouth by_ambulance at 40_pm and on admission to SGH a risk assessment was carried out by a doctor at 22.50 to assess the risk of bleeding: His weight was incorrectly stated as 80kg (approx: 12% stones) In a separate assessment carried out by a nurse she established his correct weight by simply asking Mr Hooper and he confirmed 107 kg (nearly 17 stones): This correct weight was not spotted until 14 March by a ward pharmacist and is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis (Tpx) protocol is calculated on weight Initially the plan was to give him once a when in fact because of his true weight he should have received 4Omg twice a day: On of admission it was not deemed appropriate to give any anti-coagulant drugs because of the likelihood that Mr Hooper would have surgery the following but he was given mechanical Tpx via stockings and IPC boots. Consultant Orthopaedic Surgeon, saw Mr Hooper on Sunday 13 March and after discussing his high pain levels, the doctor explained the risks and benefits of carrying out the necessary surgery to stabilise Mr Hooper's pelvic area This involved insertion of a screw into the back of the pelvis plus pins and a bar at the front. The alternative t0 surgery would have been 6 weeks complete bed rest. Mr Hooper gave informed consent and the surgery itself was uncomplicated Post operation instructions were that for the next 6 weeks Mr Hooper was not to bear weight; the external fixation would be removed; and Tpx to be given Indicated the drug Clexane was to be given for 6 weeks according to the SGH protocol. So there was no avoiding that Mr Hooper would be immobile for a considerable period because of the nature of his injuries. There was considerable discussion at the inquest about the pattem of medication post operatively. Another member of the doctor team applied the protocol and decided that 40 mg once a was appropriate working on the assumption that his weight was 80 kg: The pattern was as follows: of injury 12 March no anticoagulant drugs given the risk of bleeding and likely surgery the following 13 March _ in theatre in morning given 4Omg in evening: Clinically this was appropriate as Tpx should not be given until 6 hours after surgery; 14 March no morning dose given: At around 10.00 a ward pharmacist queried whether 40 mg once a was appropriate as it was spotted from the notes that the reported weight was in fact 107 kg so following the SGH protocol this should have been 4Omg twice a It was accepted that a moming dose should have been given immediately but this did not happen meaning there was a missed dose. An evening dose of 40 mg was given. 15 March no morning dose given as pin site was oozy: Iconfirmed at inquest that clinically this was an appropriate decision given the oozing could be due to bleeding or infection. It was confirmed that it could not be ascertained who made the decision to withhold the morning dose: Normally it would be a doctor but there is an expectation that the decision would be recorded and this did not happen: It was felt unlikely that a nurse would make the decision alone without referral t0 a doctor. However , stockings were still in use s0 some Tpx measures were still in place_ Given twice as per protocol 16 to 20 March until transferred back to QAH on 20 March: being 40mg day day day day Day day day day: daily

Mr Hooper remained at Southampton until 20 March and was transferred back to Portsmouth. Sadly at 09.27 on 22 March there was a sudden deterioration in his condition and a cardiac arrest call was but despite resuscitation he died at 10.15
a.m;

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: put out 80kg

Scott Douglas Hooper died as a result of an unexpected but recognised complication of the severity of his pelvic injuries_ The medical cause of death was: 1a) Pulmonary Embolism; 1b) Deep Vein Thrombosis; Ic) Immobility due to fractured pelvis.