A MAN who went to hospital after injuring his foot playing tennis died eight weeks later after a cardiac arrest caused by a blood clot.
Neil Martin’s death sparked a review at Queen Alexandra Hospital in Cosham as he was the second person within 18 months to die after being fitted with a ‘walking boot’ which is designed to allow a patient to stay mobile while their injury heals.
Neil, although often serious had a sharp wit, was always diligent, generous of spirit and very motivated in all thingsJulie Maby
The 58-year-old’s wife Julie Maby told an inquest into his death he was put into a walking boot and given five weeks of anticoagulant medication to prevent blood clots. He died eight weeks later on October 30 at home in Gosport.
Pathologist Barbara Borek said Mr Martin had died from a pulmonary thrombosis embolism (blood clot).
She added: ‘I felt the trauma he suffered in his heel contributed to the development of the blood clot.’
The inquest heard from Ms Maby that they went to the fracture clinic at QA Hospital on September 5 last year. She said the department was ‘chaotic’ when they visited.
‘I was concerned that it wasn’t fully staffed,’ she said.
‘It was very chaotic and Neil was very distressed.’
An X-ray confirmed Mr Martin had ruptured the tendon in his heel and he was put into the walking boot which allows movement while the injury heals.
He was also given the anti-coagulant injections but Ms Maby added they were not given a repeat prescription or told if one was needed.
They returned to the hospital on two more occasions after problems with Mr Martin’s heel but no further concerns were raised by staff.
Ms Maby criticised the hospital, saying more anti-coagulants should have been given to her husband.
QA representatives said there was an inconsistency with the length of time anti-coagulant medication was given to a patient depending on the doctor, saying it is a grey area nationally on how much should be administered.
Simon Freathy, a specialist nurse in pulmonary embolisms, investigated the death of Mr Martin for the hospital.
He said: ‘We know there could have been improvements.’
Changes put into place at the hospital include:
n more in-depth patient information leaflets on tendon ruptures in the heel.
n asking patients to list symptoms before appointments.
n asking patients to make a record of what they are being told to get consistency in appointments.
This is the second time changes have been made to fracture clinic following the death of a patient.
The inquest into the death of Stephen Mayoll, from Gosport, found mistakes were made by the hospital.
The 44-year-old injured his heel and was put into a walking boot to help with the healing. But days later, on June 22, 2013 he died from a blood clot in his lung. He was not given anti-coagulant medication.
At his inquest last November, representatives from QA said changes had been made including giving all patients with a heel injury anticoagulants. Better note taking and audits were also introduced.
Coroner David Horsley ruled Mr Martin’s death as an accident. He said: ‘Lessons have been learnt. The hospital has done its best to come up with a protocol that will address the problems in an optimum way.’
Talking about her husband, Ms Maby said: ‘Neil, although often serious, had a sharp wit, was always diligent, generous of spirit and very motivated in all things. As well as a keen musician, he was someone who relished the outdoors.
‘I was very fortunate to have nearly 23 years of his unconditional love, true friendship and zest for life.’
A spokesperson for Portsmouth Hospitals NHS Trust, which runs QA, said: ‘While the coroner did not raise any concerns about the care provided by the trust, we are pleased that he was satisfied with the action plan that has been introduced to improve the trust’s services.
‘We would like to offer the family our sincere condolences.’