Tracey Rose

[REDACTED], Chief Medical Officer, Hull & East Yorkshire, NHS Trust

I am Professor Paul Marks, Senior Coroner, for the Coroner Area of City of Kingston Upon Hull and the County of the East Riding of Yorkshire.

On 5th February 2023 I commenced an investigation into the death of Tracey Elizabeth Rose, aged 52 years. The investigation concluded at the end of the inquest on 2nd October 2023. The conclusion of the inquest was: ACCIDENT

These are set out in my summary and findings of facts which are attached. Tracey Elizabeth Rose suffered an injury on 2nd January 2023 resulting in a fracture of the right tibial plateau. This was treated by open reduction and internal fixation on 4th January 2023. She was at higher risk of thromboembolic disease due to obesity and systemic lupus erythematosus and at discharge was recommended to have a course of six weeks dalteparin. Due to a dispensing issue, she missed up to three doses. She was readmitted to Hull Royal Infirmary on 25th January with shortness of breath and dizziness. She was suspected of having a pulmonary embolism which was subsequently confirmed, but despite embolectomy using interventional radiological techniques in which a large amount of thrombus was retrieved, her heart did not restart and she died on 25th January 2023.

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) This woman was discharged home without her prescription of dalteparin being dispensed, also her last dose whilst in hospital may not have been given. Evidence was heard that missing up to three doses of this anticoagulant, in someone with increased risk factors for thromboembolic disease, may have significantly contributed to her developing a pulmonary embolism.

In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action by ensuring no doses are missed and that patients who have been prescribed such medication leave hospital with the appropriate supply.