On 26th November 2013, commenced an Investigation into the death of Carol Lynne Walker, aged sixty-eight years. The Investigation concluded at the end of the Inquest on 18th July 2014. The conclusion of the Inquest was Carol Lynne Walker had suffered a fall causing a hairline fracture of her left ankle and for a plastercast to be applied. Mrs Walker's death was confirmed at her home address, 3 Avon Court; Leeds at 0958 hours on 19th November 2013 as a consequence of her developing a pulmonary thromboembolism because of deep vein thrombosis of left leg which was a complication of her left ankle fracture. A short form conclusion of accidental death was recorded_

Carol Lynne Walker fractured her ankle on September 2013. Mrs Walker was taken by a relative to Harrogate District Hospital on Friday, 25th October 2013 where an X-ray examination revealed that she had suffered a hairline fracture to her left ankle_ This was treated by a back slab plastercast: Mrs Walker was discharged after fracture clinic follow-up had been arranged Mrs Walker was mobilising quite well on hand crutches and was receiving daily help and support from her family. It transpired that from Walker's previous medical history that she had suffered a pulmonary embolism. It is not clear whether this was communicated to those treating Mrs Walker at the hospital but there was no record made of_ the 25th Mrs this_ Quite clearly, there was an elevated risk of venous thromboembolism On Monday; 18th November 2013, Mrs Walker informed her family that she was well and that there was no need to visit, At 0930 hours on Tuesday; 1gth November 2013 she was discovered by her daughter-in-law in a collapsed state. Paramedics attended who confirmed her death at 0958 hours on 19th November 2013 A Coroner's Post Mortem examination reveals the cause of death to be 1(a) Pulmonary thromboembolism due to (b) deep vein thrombosis of left leg due to (c) left ankle fracture_

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action: It is my concern that by the nature of Mrs Whitworth's injury and the fact that her mobility would have been reduced she would have been at risk of venous thromboembolism. In her case the risk would have been heightened by the previous history of pulmonary embolism . consider that it should be standard practice, both in the orthopaedic and the emergency departments for patients to be risk assessed in respect of the administration of Chemical Thrombo Prophylaxis to patients with lower limb injuries who are immobilised in a cast, who may be considered at low risk of venous thromboembolism_