“Forno other reason than the convenience of the hospital bed-managers, he was moved at…”

The coroner’s concerns

This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.

- 1. Forno other reason than the convenience of the hospital bed-managers, he was moved at least four times from ward to ward in the hospital. 2. The quality and accuracy of the nursing and medical notes left much to be desired and it was noted that he was cared for by non-specialist nurses on a number of occasions and even when he was in the I.T.U. he was looked after by a trainee nurs 3. He was administered his anti-coagulant simply on the basis of his body weight. He weighed 99.8Kg and the difference between a daily dose of 40mg of Clexane and a twice daily dose of 40mg of Clexane is arbitrarily set at a body weight of 100Kg. Should there not be a rather more refined way of assessing the dose required? 4. In addition to the above problem, the body weight was recorded on some occasions in metric and others in imperial weights. This can and does lead to confusion. On one page of the notes, the predicted weight was shown as 15stone 10lbs which was in fact the actual weight and NOT the predicted weight. For the purpose of the accurate delivery of many drugs including anti- coagulants, accurate weight recording is essential. 5. There was a shortage of trained nurses in the hospital, and this may have led to at least one of the “ward moves”. Ward D2 was closed due to lack of staff. 6. | was told that the ideal way of elevating a patient’s leg is by using a Braun’s Frame. There was (and apparently still is) a shortage of these within the hospital, such that his leg was at all times elevated by using pillows. This was a potential for causing or contributing to the formation of DVT’s. 7. The patient was taken to theatre for the operation and this could not be started as the “kit” for the operation was found to have a non-sterile status as the outer wrapping had been breached. The operation was delayed whilst another kit was obtained but this was also found to be defective. The operation was then aborted and put off for a further two days, during which time the patient was immobile and the risk of DVT and PE was inevitably increased.

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, 2016-0228

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

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