Health board told to apologise after knee surgery patient died from blood clot

The 51-year-old died suddenly at home after an operation to repair a ruptured patella tendon.

The patient underwent surgery at the Royal Infirmary of Edinburgh (PA) (PA Archive)

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.

The board acknowledged that there was no record of a risk assessment having been carried out

Scottish Public Services Ombudsman

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.

We accept the report from the Ombudsman and have taken the recommendations extremely seriously

Alison Macdonald, NHS Lothian

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 offered its “sincere apologies” to the family of the deceased and said it accepts the report’s findings.

Alison Macdonald, nurse director for NHS Lothian, said: “I offer our sincere apologies to the family of A for the failings in this case.

“We accept the report from the Ombudsman and have taken the recommendations extremely seriously.

“An action plan is being implemented in line with the timeline in the report and we will update the Ombudsman accordingly”.