On 07 June 2024 I commenced an investigation into the death of David ABBOTT aged 72. The investigation concluded at the end of the inquest on 06 March 2026. The conclusion of the inquest was: Narrative Conclusion - David ABBOTT is remembered by his family as a ‘gentle giant’, kind, calm natured and devoted to his Family. Mr. ABBOTT was a 72-year-old man who enjoyed an active, healthy lifestyle prior to undergoing surgery on the 25th October 2023 at West Suffolk Hospital for a Transurethral Resection of his Prostate (TURP). In addition to an enlarged prostate his previous medical history included essential hypertension which was controlled through medication. Mr. ABBOTT had initially been scheduled for the TURP procedure in September 2023, however elevated blood pressure readings meant that this was rescheduled to the 25th October 2023 following adjustments to his medication which were successful in returning his blood pressure to within his target levels. The TURP procedure was successfully completed and Mr. ABBOTT was discharged the following day. Prior to his discharge, Mr. ABBOTT received advice ‘that he should not have to put any pressure or weight bear’. Mr. ABBOTT interpreted this as meaning he should keep off his feet and not mobilise, something which is contraindicated for post-operative patients following a TURP procedure. There was no medical rationale recorded for this advice and it was not indicated by any condition recorded in Mr. ABBOTT’s medical records. Nor was this advice included within the discharge documentation sent by the hospital to Mr. ABBOTT or his GP. Upon discharge, Venous Thromboembolism (VTE) Prophylaxis was not prescribed (it was not indicated) nor advice given in relation to the use of anti-embolism (TED) stockings. Following discharge, Mr. ABBOTT quickly developed discomfiture with breathing and experienced periods of back pain. This was initially likely to be due to a reaction to the general anaesthetic from the TURP procedure and an infection he contracted whilst in hospital. After the 30th October 2023, it is likely that small pulmonary emboli, which had propagated from Deep Vein Thrombosis (DVT) in his left or right calves, also contributed to these symptoms. Between the 26th October and the 30th October 2023, Mr. ABBOTT acted on the discharge advice and did not mobilise, instead resting and keeping off his feet. It is likely that this contributed to him developing DVT in his lower legs. On the 30th October 2023 Mr. ABBOTT returned to hospital for an outpatient procedure to remove a catheter. This was performed without issue. Mr. ABBOTT continued to experience breathlessness and general weakness giving rise to him calling his GP practice on the morning of the 29th November 2023 seeking a consultation with a GP. He was called back at 09.46 hours by a GP who proceeded to conduct a telephone consultation. The outcome of this consultation was a diagnosis of an infection, likely to be upper respiratory and for which antibiotics were prescribed. He was advised to contact 999 in the event that his condition worsened. At around 15.05 hours Mr. ABBOTT called 999 complaining of respiratory distress. Ambulance attended his residence at 15.18 hours where Mr. ABBOTT was found collapsed and in cardiac arrest. Resuscitation attempts were commenced, however these were unsuccessful and Mr. ABBOTT was pronounced deceased at the scene. A postmortem examination determined Mr. ABBOTT died from the effects of a Pulmonary Embolism, a naturally occurring condition. It is likely that shortly before 15.00 hours on the 29th November 2023, Mr. ABBOTT suffered a massive pulmonary embolism which led to his death. The medical cause of death was confirmed as: 1a Pulmonary Embolism

Narrative Conclusion see Part 4