In 2019, CN began suffering from heavy bleeding and was diagnosed with uterine fibroids. The Coroner for East London, Graeme Irvine, recorded in his narrative conclusion that CN was referred to the gynaecology clinic with a recommendation that she undergo a hysterectomy to treat her uterine fibroids. However, due to a failure in communication between CN and the Trust, the surgery was not undertaken. Had the surgery taken place, CN would probably not developed a pulmonary embolism in June 2022. He also noted that CN’s DVT was made more likely by her uterine fibroids and her treatment for that condition, tranexamic acid.
The Coroner also made a Prevention of Future Deaths Report, sent to the NHS Trust, NHS England and the Secretary of State for Health and Social Care, relating to two matters. First, in relation to the failure to follow up CN’s surgery, he noted that “Although the trust has investigated these circumstances and implemented change, no clear explanation could be offered for why the deceased slipped out of this care pathway. I am not satisfied that the risk of re-occurrence has been properly addressed.”
He also stated in his PFD that: “The clinicians treating CN assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors which made the formation of a DVT more likely, namely; large uterine fibroids and the use of tranexamic acid. I have concerns that the omission of these factors in the assessment criteria limited the effectiveness of the risk assessment.”