On 29 April 2014 held and concluded an inquest (and investigation) into the death of Janet BLACKMAN, aged 66, The formal conclusion was that Mrs Blackman, died on 29 May 2013,at St Richard's Hospital, Chichester, from Pulmonary Embolism due to Deep Calf Venous Thrombosis and that her death was due to Natural Causes_

In the course of early 2013, Mrs Blackman became unwell: In April 2013, she was found to be hypertensive During May she became increasingly unwell and lethargic; seeing her GP and ultimately on the late evening of 20 May 2013, was admitted to the "Admitting Medical Unit" ("AMU") via the A&E department of St Richard's Hospital, Chichester. There she was clerked in and various investigations and tests were initiated. Immediately before and on admission she was very low in mood and displaying symptoms suggesting that she was suffering from depression or some form of mental illness. The tests undertaken quickly demonstrated that she was suffering from Hyperthyroidism and, in consequence low sodium (hyponatremia): A Deep Vein Thrombosis assessment was carried out as part of the admission process the NICE pro forma and she was commenced also on low molecular weight heparin, given by injection; by way of prophylaxis_ Treatment for the Hyperthyroidism was started in the hope that addressing the organic complaint might also resolve, at least in part; the mental health issues Mrs Blackman was reluctant to eat and drink and after 2 also refused medication including the heparin prophylaxis She received a number of visits psychiatrists and it was accepted that Mrs Blackman's organic condition should first be addressed before she was referred on to the Psychiatric Unit; run by the Sussex Partnership NHS Trust. In the course of the evening of 25 May, 2013, she was considered physically fit to be discharged under s.2 of the Mental Health Act 1983 from the AMU to the Orchard Ward of the Harold Kidd Unit (HKU) Although her medication went with her, the HKU was not equipped to provide (i.e , administer) the heparin prophylaxis injections_ At about 8.20 on the morning of 26 2013, she was found collapsed in the HKU, with an oxygen saturation of between 81-85% (it should have been 96-97%), and described as "hypoxic" She was rushed back to the AMU, via the A&E department of the St Richard's Hospital, Chichester_ Her Oxygen saturation levels were quickly restored to about 94% (still low, but better) and further tests were commissioned. She was again clerked in afresh and as before a Deep Vein Thrombosis assessment was again carried out and she was again prescribed Iow molecular weight heparin; to be given by injection Some 30 hours later; in the course of the evening of 27 May, she was returned to the HKU__where as previously mentioned,the prophylaxis heparin injections could not be using days from May; early given. In the late morning of 29 May, whilst still a patient on the HKU, she was found unresponsive: Despite CPR and removal to the A&E department of St Richard's Hospital she died at 2.05 pm. Her death arose from a Pulmonary Embolus due to Deep Calf Venous Thrombosis (of both legs) . Putting aside the refusal of Mrs Blackman to accept the prophylaxis injections_ it was impossible for there to be any continuum of the prophylaxis if it could not be given to Mrs Blackman during her periods away from AMU, as a patient of the HKU. Further it was suggested by the expert that the provision and then cessation of the prophylaxis followed by the resumption (and then a further cessation) may have made a DVT more likely. It cannot be known for certain how long Mrs Blackman had been developing the DVTs that ultimately gave rise to her death and, save for the lower oxygen saturation levels, she was generally asymptomatic

In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action: