'Lessons learned' after death of Stowmarket man Paul Easlea at West Suffolk Hospital in 2014
Lessons have been learned from events surrounding the death of a Stowmarket man in hospital, an inquest has heard.
Paul Easlea, 64, had been admitted to the West Suffolk Hospital after suffering a leg injury and died from a blood clot in his lung the next day.
Because of the possibility that he might require surgery, Mr Easlea had not been given anti clot drugs and there was a lack of communication between junior doctors and nursing staff.
An investigation launched by hospital bosses concluded that documentation in Mr Easlea's case had been poor, a review of whether he should receive blood thinning medication was missed and junior doctors had not attended a meeting at which his treatment was discussed.
Today (Monday) the inquest at Suffolk Coroners Court in Ipswich was told that a new computer system introduced since Mr Easlea's death in 2014 meant that the same failings could not be repeated.
Senior Suffolk Coroner Nigel Parsley said: "There are clearly things that needed to be learned from Paul's death and it is clear that the West Suffolk Hospital has acknowledged those issues and taken steps accordingly."
Mr Easlea, of Finborough Road, Stowmarket had been admitted to hospital on April 5, 2014 after his leg gave way while working for Stowmarket Town Council at the town's recreation ground the previous afternoon.
Three colleagues who did not witness his collapse went to Mr Easlea's aid and alerted his wife. He was later taken to hospital where doctors suspected that he had ruptured a tendon, leaving him unable to stand.
After being given pain relief and while awaiting a definitive ultrasound scan to diagnose the extent of Mr Easlea's injury and possible need for surgery, his leg was put in a splint and he was encouraged to move but he was still in pain.
The inquest was told that after being taken to a toilet by a physiotherapist, Mr Easlea had collapsed, with his cries for help being heard by his wife Celia who was visiting the ward.
Medical staff found that he had suffered a cardiac arrest and worked for 45 minutes in an attempt to revive him but without success.
A post mortem examination showed that Mr Easlea had died from a pulmonary embolism.
Consultant orthopaedic surgeon Paul Nicolai said Mr Easlea had told him that he believed he had stood in a hole in the ground and felt something snap inside his knee.
Mr Easlea had not been prescribed blood thinning medication on his early morning admission to hospital because of concerns that he may require surgery to repair his leg.
Mr Nicolai admitted that the handover of Mr Easlea's care between junior doctors had "not been perfect."
The Coroner said in a letter, Mr Easlea's widow had raised concerns about his care. She had said: "Would Paul be alive today had all the right procedures been in place? It is a question that can never be answered."
Mr Parsley said there had been some communication failings leading to confusion and no potentially helpful medication to avoid a clot had been administered.
Recording a narrative conclusion, the Coroner said Mr Easlea had died from natural causes contributed to by a period of immobility caused by injury to his leg which was then splinted.
Lessons had been learned and steps taken by the hospital to improve procedures, including a computer system which would not allow access to patient records unless as required reviews and tests had been completed.
A West Suffolk NHS Foundation Trust spokesman said: "Our thoughts are very much with Mr Easlea’s family.
"It was acknowledged that we cannot know whether, had blood-thinning medication been given, it would have impacted on this sad outcome.
"However, this medication should have been given to Mr Easlea and wasn’t, and for that we are very sorry.
"Since this sad incident, we have introduced an electronic health record which makes it much easier for us to prescribe, administer and monitor this and other medications.
"We are confident that this significantly reduces the risk of something similar happening in the future, and hope this offers some comfort to Mr Easlea’s family."