A health board has been ordered to apologise to the family of a patient who died after developing a blood clot following knee surgery.
The 51-year-old ruptured the patella tendon of their left knee in a fall and underwent surgery to repair the tear at the Royal Infirmary of Edinburgh.
The patient was discharged the next day with a hinged knee brace and invited to attend a fracture clinic two weeks later.
A plan was made for the patient to progress gradually with the brace and a follow-up appointment was arranged four weeks later.
The patient died suddenly at home the next day, however, and a probe was launched by the Scottish Fatalities Investigation Unit to determine the cause of death.
READ MORE: 'Alarming' increase in the number of under-40s diagnosed with Type 2 diabetes
The investigation found the death was the result of pulmonary thromboembolism, deep vein thrombosis (DVT) and the recent leg surgery.
A sibling of the deceased complained to the Scottish Public Services Ombudsman (SPSO) that their relative was not appropriately assessed and treated for blood clot risk.
In their complaint response, NHS Lothian said the patient’s blood clot risk was assessed and they were not prescribed blood-thinners as they had no high-risk features for blood clots.
A further investigation carried out by the SPSO found the health board failed to complete a risk assessment for the patient developing a blood clot following their surgery.
An SPSO report, which identified the patient only as A, said: “In response to our inquiries, the board acknowledged that there was no record of a risk assessment having been carried out.
“The board said a further investigation by the service identified that A was in fact prescribed and administered one dose of DVT/anticoagulant medication.
“They apologised for the inaccurate information previously provided but provided no further evidence or documentation in support of their position.”
The SPSO investigation also found the board failed to note the patient’s body mass index as a risk factor and did not identify additional risk associated with anaesthesia time.
It further found NHS Lothian did not have a protocol in place to help prevent blood clots in veins in its orthopaedic department and failed to undertake a significant adverse event review for the unexpected death in line with national guidance.
In addition to the requirement to apologise to the patient’s family, the SPSO has also ordered the board to properly assess the risk of patients undergoing surgery developing blood clots in veins and ensure adverse event reviews are held when necessary in future.
The board told the ombudsman it has begun drafting a protocol to help prevent blood clots in veins for the orthopaedic department.
NHS Lothian has been approached for comment.
Why are you making commenting on The Herald only available to subscribers?
It should have been a safe space for informed debate, somewhere for readers to discuss issues around the biggest stories of the day, but all too often the below the line comments on most websites have become bogged down by off-topic discussions and abuse.
heraldscotland.com is tackling this problem by allowing only subscribers to comment.
We are doing this to improve the experience for our loyal readers and we believe it will reduce the ability of trolls and troublemakers, who occasionally find their way onto our site, to abuse our journalists and readers. We also hope it will help the comments section fulfil its promise as a part of Scotland's conversation with itself.
We are lucky at The Herald. We are read by an informed, educated readership who can add their knowledge and insights to our stories.
That is invaluable.
We are making the subscriber-only change to support our valued readers, who tell us they don't want the site cluttered up with irrelevant comments, untruths and abuse.
In the past, the journalist’s job was to collect and distribute information to the audience. Technology means that readers can shape a discussion. We look forward to hearing from you on heraldscotland.com
Comments & Moderation
Readers’ comments: You are personally liable for the content of any comments you upload to this website, so please act responsibly. We do not pre-moderate or monitor readers’ comments appearing on our websites, but we do post-moderate in response to complaints we receive or otherwise when a potential problem comes to our attention. You can make a complaint by using the ‘report this post’ link . We may then apply our discretion under the user terms to amend or delete comments.
Post moderation is undertaken full-time 9am-6pm on weekdays, and on a part-time basis outwith those hours.
Read the rules here