“Important information relating to advice concerning the prescription of anti-coagulation…”

The coroner’s concerns

Important information relating to advice concerning the prescription of anti-coagulation therapy (low weight molecular heparin - LWMH) for venous thromboembolism (VTE) prophylaxis and which was contained in Mr. Smith’s medical records, was not flagged for clinican attention as part of the electronic records management system in use at West Suffolk Regulation 28 – After Inquest Document Template Updated 30/07/2021 Hospital. This meant that when Mr. Smith was readmitted on the 25th August 2023, this information did not form part of the reviewing consultants considerations around whether to precribe tinzaparin (LWMH) to Mr. Smith for VTE prophalaxis. He subsequently recived 8 doses of tinzaparin which contributed to him suffering a catastrophic stroke that led to his death. During both admissions to West Suffolk Hospital during the period April to August 2023, Mr. Smith and his Family fiercely advocated for considerations associated with his cerebral amyloid angiopathy (CAA) to be taken into account as part of his care and treatment. This occurred during Mr. Smith’s first admission between 14th April and 21st August 2023 with alternative management used to address the VTE risk. This did not occur during Mr. Smith’s second admission from 25th August 2023 and despite Mr. Smith declining tinzaparin on two occasions, the medication continued to be administered without adequate consideration as to why Mr. Smith had declined it or by engaging in consultation with either Mr. Smith or his Family. There was limited input from the West Suffolk Hospital stroke team into Mr. Smith’s care and treatment during the period following his admission on the 14th April 2023 until his stroke on the 1st May 2023. This was notwithstanding Mr. Smith and his Family raising on multiple occasions the increased risk of stroke to Mr. Smith due to his pre-existing CAA condition. Following his stroke on the 1st May 2023, measures taken to diagnose the stroke, move Mr. Smith to a stroke unit and correctly manage his blood pressure in accordance with NICE guidelines were slow, and with respect to blood pressure management, non-concordant with existing national stroke guidance. I am concerned that the West Suffolk Hospital patient records management system is ineffective in accurately highlighting important information which should inform patient care and treatment. I am concerned that communication processes at West Suffolk Hospital between patients and hospital staff (including treating clinicians) are ineffective in affording patients and their families with adequate opportunity to engage with and inform clinical decisions around their care and treatment. I am concerned that effective procedures are not in place at West Suffolk Hospital to deliver timely specialist stroke team input for the purposes of managing stroke risk as part of a multi-disciplinary team approach for patients admitted with conditions that expose them to higher risk of VTE (e.g. CAA).

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0069

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0