Missed opportunities before the death of Powys man from blood clot, inquest hears

Geoffrey Thomas Harper, 56, of Nelson Street, Llandrindod Wells died at his home on July 28 2024 eight days after being discharged from hospital after undergoing treatment for a significant lower leg infection.

Geoff, as he was known, suffered with cellulitis in his left leg which had become infected and he was admitted to Hereford Hospital on July 13 for incision and drainage.

At the hospital, forestry worker Geoff, who was a large man and described as a 'gentle giant', was given anti-coagulant medication but it was correctly stopped on the proposed day of an operation and the actual day of a short operation to treat his leg.

He was discharged on July 20 2024 with a Vacuum Assisted Closure dressing but no blood thinners.

Back at home he struggled to move other than to use the toilet and he repeatedly raised concerns about blood clots and whether he should have anti-coagulant medication, because of his inactivity, obesity and other health issues such as diabetes.

He asked the district nursing team who visited to change his leg dressing whether he should have anti-coagulants and they said they would ask the GP. The medical practice said it was waiting for the hospital discharge notes.

On July 28 2024 Geoff reported chest pain, breathing difficulties and restlessness. He was clammy, pale and he collapsed. His wife called 999 and first responders from the fire service attended and when he went into cardiac arrest they gave him CPR as did the Welsh Ambulance Service paramedics when they arrived from Caersws but sadly he died at home.

An inquest at Pontypridd Coroner's Court last week heard that when he was discharged there was some confusion about how mobile he was and whether he should have been prescribed anti-coagulant medication to take home.

South Wales Central Area Coroner Rachel Knight said there were several missed opportunities in relation to Geoff's care.

She said there was a missed opportunity not to gauge his mobility when he was admitted to hospital and it would have been a useful comparison for assessing his mobility when he was discharged.

Ms Knight said there was some confusion at the hospital between the different medical teams as to who should take decisions about Geoff's care, there was also a lack of clarity about what the term 'weight bearing' meant and its relationship to mobility and there was inadequate document keeping at Hereford Hospital and a lack of information about Geoff's mobility on discharge.

She said the decision not to prescribe anti-coagulants on discharge may have been correct but it should have been re-assessed in the community by the district nurses or the GP practice after Geoff raised concerns about a risk of blood clots.

Ms Knight said Geoff did all he could to raise the issue but it was not dealt with adequately and it would have been prudent to make further enquiries with Hereford Hospital and undertake a further assessment.

Ms Knight said the district nurses when they asked about anti-coagulant medication were told the GP's were still waiting for the discharge notes from Hereford Hospital.

She said the delay in sending a discharge note was poor, but more action could have been taken in the community to chase it up or to look at Geoff's written copy – another missed opportunity.

“The fact that Geoff had repeatedly raised concerns about a blood clot makes this case so much more tragic and the worst went on to happen. I accept that until July 28 Geoff did not display any clinical signs or symptoms of a deep vein thrombosis (DVT), when he deteriorated and tragically died” Ms Knight said.

She said the ambulance response rate was adequate but because of the geography of Powys it was necessarily delayed.

She said the medical cause of death Pulmonary Thromboembolism, lower leg cellulitis, diabetes mellitus, and cardiomegaly.

Ms Knight said the lack of a reassessment of his DVT risk in the community was another missed opportunity but she accepted anti-coagulants may not have helped but the risk may have been reduced.

She gave a narrative conclusion and she asked the Wye Valley Trust, Powys Teaching Health Board and Llandrindod Wells GP Medical Practice to write to her by the end of April about issues she raised during the inquest and steps they have taken to address them or improvements they have made.

Ms Knight extended her condolences to Mr Harper's family and said she was so sad they lost Geoff in this way and was sorry the inquest had dragged on for two years.

Giving evidence to the inquest, Mrs Harper said before this incident Geoff was physically strong and able and he would volunteer at rally driving events most weekends and they adopted many dogs mainly from animal rescue centres.

She said he had worked since he was 15, driving logging lorries before changing to forestry work and they hoped to move the seaside when he retired He wanted a gastric band to lose weight and was on a waiting list.

Mrs Harper said Geoff was her carer and her life had completely changed since his death.