Margaret Heal: Prevention of Future Deaths Report
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Date of report: 6/12/2023
Ref: 2024-0368
Deceased name: Margaret Heal
Coroner name: James Thompson
Coroner Area: Durham & Darlington
Category: Other related deaths
This report is being sent to: REDACTED
| Margaret Heal – Prevention of Future Deaths Report | |
|---|---|
| THIS REPORT IS BEING SENT TO: [REDACTED] | |
| 1 | CORONER I am James E THOMPSON, Assistant Coroner for the coroner area of County Durham and Darlington |
| 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. |
| 3 | INVESTIGATION and INQUEST On 25/07/2022 14:17an investigation was commenced into the death of Margaret HEAL 30/07/1935 00:00:00. The investigation concluded at the end of the inquest on 06/12/2023 00:00. The conclusion of the inquest was that Margaret Heal died on 12th July at her home, [REDACTED] from a massive pulmonary thromboembolism which had caused by a deep venous thrombosis. This is a natural disease running its full course and resulting in her death. She had stopped taking her anti-coagulant medication on medical advice 10 days prior to her death to undergo surgery. She did not resume this medication after it. It is unclear on the evidence if she was unaware of the need to resume the medication or she chose not to resume the medication. |
| 4 | CIRCUMSTANCES OF THE DEATH Margaret Heal died on 12th July at her home, [REDACTED] from a massive pulmonary thromboembolism which had caused by a deep venous thrombosis. This is a natural disease running its full course and resulting in her death. She had stopped taking her anti-coagulant medication on medical advice 10 days prior to her death to undergo surgery. She did not resume this medication after it. It is unclear on the evidence if she was unaware of the need to resume the medication or she chose not to resume the medication. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) During the course of the inquest it became apparent there was no evidence to show the deceased had been provided with a document instructing her to resume her anti coagulation. Whilst this requirement is set out in the Trust’s procedures, no evidence was found it had taken place. No document was found in Mrs Heal’s home at the time of her death. It is of concern that Mrs Heal was an 86 year old lady living alone after her discharge from hospital. Is there more that can be done to ensure patients particularly who are vulnerable and / or elderly are given advice regarding recommencement of drugs in a manner, to ensure as far possible, they are aware of the need to recommence their medication. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by January 31, 2024. 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 [REDACTED] I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 | Dated: 06/12/2023 James E THOMPSON Assistant Coroner for County Durham and Darlington |