Father's death after bike crash could have been avoided - coroner
Hospital medics have apologised and vowed to make changes after admitting the death of a 51-year-old father was ‘avoidable’.
Wayne Pitchford suffered rib and spinal fractures after he lost control and came off his motorbike on the B5062 between Roden and High Ercall on June 18, 2017.
He died at the Royal Stoke University Hospital on July 22 of a pulmonary thromboembolism, resulting from a deep vein thrombosis.
But an inquest in Shrewsbury concluded that, had Mr Pitchford been offered prophylactic blood thinning medication after being discharged, his death could have been avoided.
The hearing at Shirehall heard Mr Pitchford was first admitted to Royal Shrewsbury Hospital following the accident, and was discharged on Friday, June 23.
Dr Mark Cheetham, who saw Mr Pitchford during his stay at RSH, told the inquest he was not initially given blood thinners as there was a risk they could cause internal bleeding and a spinal cord injury.
This was despite Mr Pitchford having a rare gene mutation which increased his susceptibility to blood clots.
He was however given elasticated socks when he was first admitted and, after further scans, had anticoagulant injections, which prevent clots forming, on June 20 and 22 before being discharged the following day. Dr Cheetham said he assessed Mr Pitchford as being mobile when he was allowed home.
This was disputed by Mr Pitchford’s wife, who said her husband rapidly deteriorated as he was sent home with just paracetamol and ibuprofen, despite being on morphine at the hospital, and the pain reduced his mobility.
Dr Cheetham apologised and said in hindsight Mr Pitchford should have been prescribed stronger painkillers to take home.
Mr Pitchford, of Hyde Lea, Stafford, was then admitted to Stafford County Hospital on June 27 and transferred to RSUH where he stayed until July 6.
During this time he was again given anticoagulants, but that hospital also failed to offer blood thinners to take home.
Dr Adrian Large, consultant cardiologist at the Royal Stoke Hospital, said the hospital had probed Mr Pitchford’s death and found that blood thinning medication “should have been continued beyond the point of discharge because of the gene mutation”.
Mrs Pitchford said she had made both hospitals aware of her husband’s condition but her concerns were “pushed to one side”.
Dr Large apologised ‘on behalf of the team involved and on behalf of the trust’ and said actions would be taken to reduce future risk.
John Ellery, senior coroner, concluded Mr Pitchford died from an avoidable natural cause.
Summing up, he said: “Mr Pitchford’s death was avoidable had he been offered anticoagulants upon discharge from the Royal Stoke University Hospital.
"I have not heard evidence that it probably would have made a difference, but that it possibly may have done.
"It is possible that the risk may have been further reduced had there been a clinical judgement for such treatment on earlier discharge from the Royal Shrewsbury Hospital.”
