Robert Dymond
25 Jul 2017 · Coroner Emma Whitting · Coventry
The coroner's concerns
1. delayed diagnosis of DVT
“Following referral to the UHCW DVT Clinic by his GP on 22 November 2016 with a suspected DVT, Mr [name redacted], having a Wells score of 2, was assessed as being 'likely' to be suffering from a DVT - the investigations included a D-Dimer blood result of 0.97 - and he was discharged home with instructions to self-administer therapeutic LMWH (Clezane) doses at home twice daily in his stomach pending an ultrasound scan booked for 25 November 2016. The scan performed on 25 November 2016 apparently revealed”
2. lack of awareness of prior DVT investigations
“Neither the Consultant [name redacted] nor the Anaesthetist performing the operation on 9 March 2017 had been made aware of the DVT investigations/treatment in November 2016”
3. omission of DVT history in pre-operative assessment
“The DVT investigations/treatment in November 2016 did not appear to feature in the second pre-operative assessment carried out on 12 January 2017”