An inquest into the death of a patient at East Surrey Hospital found that care omissions materially contributed to the development of blood clots which caused his death. 

An inquest has found there were significant omissions in the care given to a 32-year-old man at East Surrey Hospital before his death, and that his overall care should have been better. 

The patient had diagnoses of autism, epilepsy and a learning disability. He died on 8 July 2024 at St George’s Hospital in London as a result of blood clots impacting his bowel. 

Concluding the inquest in mid-May, at Surrey Coroner’s Court, the assistant coroner, Karen Henderson, found that he was not given the blood-thinning medication for 14 consecutive days, with no risk assessments carried out during that time. This was despite the patient having multiple risk factors, including being immobile, having a recent diagnosis of Covid-19 during his admission, and a raised BMI, all of which materially contributed to the development of the pulmonary embolism. 

As a result of the inquest, the coroner will now write a prevention of future deaths report to highlight his case and the need for joining up physical and mental health care in such cases. It is understood this report will be sent to the secretary of state for health & social care, NHS England, the parliamentary and health services ombudsman, the minister for women & equalities, and the Integrated Care Board for Surrey & Sussex. 

Risk factors

The patient had previously been treated at East Surrey Hospital (part of Surrey and Sussex Healthcare NHS Trust) after suffering a deterioration in his mental health, which was out of character.  

He was subsequently detained under the Mental Health Act and prescribed antipsychotic drugs. During his time at East Surrey Hospital, the patient contracted COVID-19 and developed a pulmonary embolism. On 2 July, he was transferred to St George’s Hospital for emergency surgery, but six days later, he died as a result of the blood clots. 

He was prescribed a standard blood-thinning medication called Enoxaparin on his admission to East Surrey Hospital. The patient had various other risk factors that increased his risk of clotting, including his weight, his lack of mobility during hospitalisation, prescription of antipsychotic drugs, and infection with COVID-19, but, despite this, there was a period of two weeks, from 17 to 30 June 2024, when East Surrey Hospital did not administer any blood-thinning medication. 

Failure to administer

The inquest, which began on 4 June last year and resumed at the very end of March this year, heard evidence from three of the doctors who treated the patient: Ben Mearns and Patrick Morgan, from East Surrey Hospital (part of Surrey and Sussex Healthcare NHS Trust), and Hilary Foster, a consultant psychiatrist from Surrey and Borders Partnership NHS Trust. Evidence was also heard from Muhammad Sardar, a consultant in general and geriatric medicine. 

Mearns, a consultant physician in acute and elderly medicine at East Surrey Hospital, told the inquest that he recognised the effect of failing to give the patient the prescribed Enoxaparin put his life in danger. The family’s view is that, if this medication had been administered appropriately, he may have survived. The coroner found that the failure to administer the blood-thinning medication, together with his multiple risk factors, materially contributed to the development of pulmonary embolism.

“The evidence heard at [the] inquest has raised important issues around the role that families and carers play in supporting patients in hospital, particularly those with autism or learning disabilities, and those experiencing mental health crises,” said Sarah Westoby, senior associate solicitor at Leigh Day in London, who acted for the family. 

“The coroner’s conclusions include criticism of the care [he] received, noting that the risks… were heightened and not receiving appropriate medication was one of the factors which materially contributed to his death,” she added.