Finding of Neglect following London Hospital failure to provide prescribed anticoagulants.

Peter Mordecai is instructed to represent the family of the deceased, Philip Wood, in a Clinical Negligence matter against Guy’s and St Thomas’ NHS Foundation Trust. The claim involves a failure to provide heparin after a below the knee amputation despite this being the intention. As a result, Mr Wood suffered bilateral pulmonary emboli and sadly lost his life.

An inquest was held before Assistant Coroner Dr Philip Barlow on 13^th April 2018. Isaac Hogarth of 12 King’s Bench Walk chambers was instructed to represent the family at the inquest.  The Coroner made the following findings as to why there was a failure to give heparin:

1. The post-operative instructions on 13 January 2017 did not state that heparin should be given.
2. Unusually, Mr Wood was stepped down from HDU to the ward after the BKA. The consequences of this were:
   1. He was moved to a different electronic medication recording system (to Medchart, from Carevue).
   2. There was no direct nurse to nurse handover from HDU to the ward.
3. The prescription for heparin was recorded on the Medchart system. However, the heparin was to be given as a variable rate infusion, to be titrated against blood test results. The Medchart system (unlike the Carevue system used on HDU) requires a supplemental paper chart to be completed, setting out the instructions for the variable rate infusion. Without this paper chart the heparin cannot be given. The supplemental paper chart was never created.
4. The fact that heparin was prescribed on Medchart but was not being given was noted by the nurses (who marked it as “withheld”) but not escalated to the doctors.
5. On the weekend ward rounds on 14 and 15 January, the junior doctors checked on Medchart and saw that heparin was prescribed. However, they did not open the further tab which would have shown whether or not it was actually being given.
6. A pharmacy review on the evening of Sunday 15 January did not identify that the heparin was being withheld.
7. On the pre-op ward round on 13 January Mr Patel instructed that heparin should be given after the BKA, but his instruction was not recorded in the medical records.

The Coroner’s concluded that Mr Wood suffered fatal pulmonary emboli following surgery after prescribed heparin was not given. His death was contributed to by neglect.

Peter Mordecai said, ‘This was a tragedy that should never have been allowed to happen and as a result a loving husband, father, and grandfather has lost his life. We hope that the Hospital learns from this and takes steps to ensure that such failings never happen again.’