Man dies from blood clot in hospital
Madoc Bellamy died from a blood clot after hospital staff failed to perform a VTE (venous thromboembolism), which looks for blood clots, sooner.
Mr Bellamy had to have his foot amputated following cancer fears. Staff at Nottingham University Hospitals (NUH) Trust didn’t give the 54-year-old a blood thinner before or after his operation, which would have helped to avoid clotting.
The staff at the hospital ignored warnings on the hospital’s computer that the clotting assessment hadn’t been done.
When the assessment was finally carried out the consultant discharged him without giving him the blood thinner, despite the assessment saying he required it.
The inquest into Mr Bellamy’s death found that he had seen 11 doctors and nurses for his initial food problem and was referred to hospital seven months after visiting the surgery with his condition.
Recording a narrative verdict, the assistant coroner Hedi Connor said: "Mr Bellamy underwent surgery on March 8, 2016, to remove a malignant melanoma on his right foot.
"Enoxaparin was not prescribed or administered post-operatively. He developed a pulmonary embolism and died on March 16, 2016. The lack of enoxaparin contributed to development of the pulmonary embolism and his subsequent death."
The inquest heard that when he arrived at hospital Mr Bellamy saw Dr Ian Starely, a consultant plastic surgeon, who said the lesion on his foot was one of the largest he’d seen in his 17-year career.
Dr Starley said: "I really don't understand it. I've thought about it. I think the problem is that it's been assumed that the consultant has done the risk assessment and the consultant has therefore decided it's not to be given."
At the end of the inquest, Mr Bellamy's daughters paid tribute, with one saying: "He was very much the life and soul, a very likable character. He just made everyone feel really good about themselves.”
Dr Keith Girling, deputy medical director for the Trust, said: "We offer our condolences to Mr Bellamy's family. We have completed a detailed internal investigation to understand what happened and have shared this with both the family and coroner.
"We have made a number of changes to our practices and protocols since this incident which mean a patient cannot go to theatre or leave without a venous thromboembolism risk assessment taking place which will reduce the chance of this happening again."
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