Coroner highlights hospital failings after death of Whipps Cross patient

A Whipps Cross patient died after receiving a “suboptimal” dose of medication for four days, an inquest revealed this week.

Raymond Maxwell, 67, died on September 8, 2019 of a pulmonary embolism, meaning blood clots from a deep vein thrombosis elsewhere in his body blocked the arteries in his lungs.

Raymond was admitted to the Leytonstone hospital on September 4 and was prescribed Inhixa, a blood thinner. However, according to hospital guidelines, he received only half the dose he should have.

At his inquest’s conclusion, coroner Nadia Persaud said there were “clear failings” in his care and “poor clinical decision making” regarding his risk of venous thromboembolism (VTE).

She said: “At no time during his four-day admission was a full and accurate VTE risk assessment carried out.

“The trust guidelines required him to receive 40mg twice-daily [because he weighed more than 100 kilograms] but he was prescribed and administered once daily.

“This reduced dose was recognised by two pharmacists, who documented on the drug chart the need for his dose to be adjusted but did not draw this to the attention of the medical team.

“Had he been provided with a dose in accordance with the trust’s guidelines, this would have provided more assurance that all that could have been done to prevent the fatal pulmonary embolism was done.

“But, on the evidence available, it is not possible to conclude a higher dose would have prevented his death.”

The court heard evidence from Dr Chris Miller, who is unconnected to Whipps Cross or its trust Barts Health, that there is overall a “lack of evidence” on whether heavier patients need a higher dose of Inhixa.

The coroner also noted in her conclusion that the National Institute for Health and Care Excellence does not require patients of Raymond’s weight to receive a double dose.

However, she remained concerned by the three assessments of his risk of developing VTE carried out during his stay in hospital.

None of the three doctors, two of which have not been identified, spotted all the risk factors in his case: his age, obesity and history of deep vein thrombosis.

The third doctor, only four weeks into her medical practice, gave evidence that she rushed an electronic assessment purely to view his notes, as accessing them was not possible until it was done.

She added that she intended to go back and fill it out properly later, although this never happened.

The day before his death, Raymond was seen by a registrar [ward round doctor], who told the court he noticed the low dose but “decided against” increasing it to avoid raising the risk of an internal bleed.

The coroner considered this “poor clinical decision making” because, after realising guidelines were not being followed, there “should have been careful consideration of the risk of both bleeding and VTE”.

She decided against concluding Raymond died of “natural causes” and opted for a narrative conclusion, arguing the hospital’s failings were “closely connected” to his cause of death.

She added she was still deciding whether to write a report to prevent future deaths and was awaiting more evidence from Barts Health NHS Trust on how it had learned from the incident.


Victoria Munro

Local Democracy Reporter