On the 28 th May 2014 I commenced an investigation into the death of Nicholas James Megginson, aged 45 years. The investigation concluded at the end of an inquest on the 6th August 2014. The conclusion of the inquest was that of a narrative conclusion; "Nicholas James Megginson died from effects of apulmonary thromboembolism arising from him fracturing his ankle when he fell on the 51 May 2014. He was considered high risk for developing a thromboembolism by virtue of the fracture and his underlying vascular impairment. Whilst he was prescribed prophylaxis for venous thromboembolism which was administered after his surgery on the elh May, he was not prescribed anything thereafter" The medical cause of his death was recorded as:­ 1a. Pulmonary Thromboembolism 1b. Deep Venous Thrombosis 1c. Fractured Left Ankle (operated 06/05/2014)

The deceased was found unresponsive by his wife at the home address on the 22nd May 2014. He had ~reviously fractured his left ankle on the 51h May 2014 and had an operation on 61 May before being discharged home on yth May. A post mortem examination found that he had died from the effects of a pulmonary embolism.