Date of report: 06/10/2023
Deceased name: Adam Stuyvesant
Coroner name: Ian Singleton
Coroner Area: Wiltshire and Swindon
Category: Road (Highways Safety) related deaths | Child Death (from 2015)
This report is being sent to: The Great Western Hospital
|REGULATION 28 REPORT TO PREVENT FUTURE DEATHS|
|THIS REPORT IS BEING SENT TO: |
The Great Western Hospital, Marlborough Road, Swindon
I am Ian Singleton, Area Coroner for Wiltshire and Swindon
|2||CORONER’S LEGAL POWERS |
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http:/ / www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http:/Lwww.legislat i on.gov.uk/uksi/2013/1629/part/7/made
|3||INVESTIGATION and INQUEST |
On 2 September 2022 I commenced an investigation into the death of Adam Connelly STUYVESANT. The investigation concluded at the end of the inquest on the 6 October 2023.
The conclusion of the inquest was:
On the 17 August 2022 Adam Connolly Stuyvesant was involved in a minor, single vehicle road traffic collision, on the Marlborough Road at Pewsey Wiltshire. He was admitted to The Great Western Hospital Emergency Department, Marlborough Road, Swindon, where in addition to minor injuries he was diagnosed with an avulsion fracture from the lateral malleolus in the left ankle. Adam was given a plastic boot to wear which immobilized the ankle. At that time, the DVT risk assessment had it been carried out would only have taken account of Adam’s size, not the ankle immobility, which carried a risk of deep vein thrombosis. On the 22 August 2022 Adam collapsed at Unit 31 Blackworth Industrial Estate, Highworth, Swindon and despite best efforts at resuscitation, died. The post mortem confirmed that death was due to the immobilisation of the left ankle allowing a deep vein thrombosis to develop which led to pulmonary embolus.
la Pulmonary Embolus
lb Deep Vein Thrombosis
le Lower Limb Immobilisation Secondary to Injury after Road Traffic Accident
|4||CIRCUMSTANCES OF THE DEATH|
See Box 3 above
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
(1) The wearing of a plastic boot can lead to lower limb immobility and the possibility of a restriction in the “calf pump function” which can lead to deep vein thrombosis.
(2) The DVT risk assessment in use in the Emergency Department at The Great Western Hospital, made no provision to take account of the immobilisation when considering whether anti-clotting medication should be prescribed.
(3) That without taking account of the immobility, as part of the DVT risk assessment, further patients may not be prescribed anti-clotting medication and as a result develop DVT, resulting in death from pulmonary embolus.
|6||ACTION SHOULD BE TAKEN|
In my opinion action should be taken to prevent future deaths and I believe you, The Great Western Hospital, have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 5 December 2023. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.
|8||COPIES and PUBLICATION|
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Adam Connolly Stuyvesant.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
|9||6 October 2023|
Ian Singleton, Area Coroner for Wiltshire and Swindon