A student who underwent back surgery died in his mother’s arms after being allowed home without ‘clear instructions’ on a life-threatening complication and having missed a dose of medication to help prevent it, an inquest heard.
A coroner has now slammed the hospital for not following discharge procedure which she said increased the risk of Rhys Hill developing the blood clot that killed him.
Rhys, 20, from Stockport, underwent a procedure to release pressure on spinal nerves at the Royal Hospital in Preston, Lancs, the city where he was attending university, on January 27 this year.
Try MEN Premium now with our amazing New Year offer… just click here to give it a go.
Three days later he returned to the family home in Cheadle Hulme to recover. However ten days after that, on February 9, he rang his mother from his upstairs bedroom to tell her he was struggling to breathe.
She rushed up to him but found he had stopped breathing. She began CPR as paramedics rushed to the property on Vernon Close. However, he could not be saved. He was found to have suffered a blood clot which a coroner has now ruled was likely a result of the surgery.
An inquest into his death at South Manchester Coroner’s Court in Stockport heard that early on January 30, the day he was discharged from Royal Hospital Preston, he was offered an injection of the anticoagulant drug, Dalteparin, used to help prevent Venous thromboembolism (VTE) – a blood clot that forms in a vein, but that he refused it.
The inquest heard Rhys, who was born in Dublin, Ireland, and who moved to Greater Manchester in 2011, had a number of ‘additional needs’ including Attention Deficit Hyperactivity Disorder (ADHD) and Emotionally Unstable Personality Disorder (EUPD).
His diagnosis ‘effectively amounted to a learning disability’ the hearing was told. He also had a history of self-harm and suicidal ideation. It was during a visit to A+E where he had to be restrained that the family claim he suffered the back injury which later needed surgery.
Giving evidence, Rhys’ mother Karen Hill described him as ‘like a child in many ways’ but said he was ‘very intelligent.’ She said he enjoyed walking the dog but ‘used to stay in his room a lot and read books.’
She said she received ‘no communication’ from hospital staff on the day of his procedure, who she said claimed didn’t have her phone number, despite her claiming they had already rung her earlier that day.
She said she was ‘shocked’ at how quickly he was allowed home given the breathing difficulties he suffered after a previous operation in 2021 and how long he was in surgery.
She said it also ‘surprised’ her when she later learned of his refusal to take the Dalteparin as he was ‘obsessive’ and ‘the thought of injecting himself would have seemed cool to Rhys.’
Senior Coroner Alison Mutch said she had concluded that ‘on the balance of probabilities that refusal was linked to the time it was offered at and because he was in some discomfort.’
“The refusal of Dalteparin was not escalated to the clinical team and there is no evidence that the risk presented by the omission of the dose of Dalteparin was evaluated by the treating clinicians,” she said. Rhys was discharged home without any medication.
Ms Hill said she was also never told about the ‘signs and symptoms’ of VTE and what to look out for. Ms Mutch said: “The Trust policy required that at discharge a patient and their family members must be provided with verbal and written information about VTE.
“The Trust policy was not followed. As a consequence, Rhys and his family did not have clear instructions on how to reduce the risk of developing a VTE and the symptoms to look for. This probably increased the risk of Rhys developing a VTE.”
Following his collapse resuscitation attempts were unsuccessful. A post-mortem concluded his cause of death was 1A) pulmonary embolus, caused by 1B) deep vein thrombosis in the context of recent Primary Lumbar Discectomy.
Ms Mutch said: “On the balance of probabilities the cause of his deep vein thrombosis was the recent surgery he had had undertaken. “The risk of him developing a deep vein thrombosis was increased by the Trust discharge policy not being followed and a risk assessment not being undertaken following his refusal of the Dalteparin on the morning of the discharge.”
Following the inquest which concluded on Wednesday, December 20 last year, Ms Mutch recorded a narrative conclusion that Rhys ‘died from a complication of a previous surgical procedure, where the complication was not identified until after his death.’
She also said she would be writing a prevention of future deaths (PFD) report requiring the trust that runs the hospital to take action to ensure such a tragedy doesn’t happen again.
A spokesperson for Lancashire Teaching Hospitals NHS Foundation Trust said: “We would like to offer our sincere condolences to Rhys’ family. “We are committed to taking the required action with the aim of ensuring that such deaths do not occur in the future.
“Once we receive the full Preventing Future Deaths report we will provide a formal response back to the Coroner, underlining our commitment to learn from this very sad case.”
Gareth Naylor of Ison Harrison solicitors, who represented the family, said following the hearing: “Rhys was a vulnerable patient in terms of both his physical and mental health.
“Despite these vulnerabilities, Rhys’ surgery was a success. However, Trust policy on VTE was not followed post-surgery which meant that Rhys and his mother, on whom he relied upon heavily, were not educated on the risks of VTE nor was there any risk assessment upon discharge to consider the risks of Rhys developed a VTE and whether further anticoagulant medication would be required.
“I am pleased that the Coroner identified that Rhys’ refusal of critical medication, when he was woken early after only a couple of hours sleep, was not escalated to the clinical team and that there was no evidence that the risk presented by the omission of the dose was evaluated by treating clinicians.
“The learned Coroner also identified that Trust policy was not followed upon Rhys’ discharge and as a consequence, Rhys and his mother did not have clear instructions on how to reduce the risk. Rhys did sadly suffer a fatal pulmonary embolism at home on the 9 February 2023 and tragically died in his mother’s arms.
“The Coroner was so concerned with the lack of record keeping, poor communication between staff, management of medications and the discharge process that she is issuing a Prevention of Future Deaths report.”
Sign up to our Stockport newsletter to get the latest updates to your inbox
Dr. Thomas Hughes is a UK-based scientist and science communicator who makes complex topics accessible to readers. His articles explore breakthroughs in various scientific disciplines, from space exploration to cutting-edge research.
