Poor communication between Southampton Hospital and the Princess Elizabeth Hospital in Guernsey has been highlighted but it did not contribute to a woman's death, a Court Inquest has been told.
50-year-old Selena Le Page died at the PEH on 9 June 2017 because of a deep vein thrombosis.
She was in the midst of recovering from a stroke, having been treated in Southampton, but was never prescribed anticoagulants because of the lacking medical information doctors in Guernsey had to work with.
An expert report has concluded that there were failings in Mrs Le Page's care, but they were not central to her cause of death, and so after 20 months the court was able to return a verdict of death by natural causes.
The inquest itself started on 26 July 2017 after Mrs Le Page's family raised concerns about the quality of her care.
Pictured: The inquest concluded yesterday.
Having been transferred to Southampton after her initial stroke, Mrs Le Page was set to recover in hospital in Guernsey, and returned to the island on 6 June. She was considered to be stable until the early afternoon on 9 June, when she complained about being breathless. Half an hour later, just before 13:40 she suffered a cardiac arrest, and by 14:00 she had died.
A post mortem examination found the cause of death to be a massive pulmonary embolism due to deep vein thrombosis, but after the family raised their concerns, an investigation was started by the Health Authorities, along with the opening of the inquest.
It all concluded on Friday, after nearly two years of investigations.
A root cause analysis found there was no specific reason for the death, but identified two factors that could have led to the DVT: one, the hand over from Southampton to Guernsey was inadequate, and meant no anticoagulants were prescribed, and two, the VTE assessment form the PEH was using wasn't good enough at the time (this has since been improved).
Pictured: Full investigations were launched after the family's complaint.
The root cause analysis led to a report being commissioned by Dr David da Costa, a Consultant from Sheffield.
He concluded that there had been failings in the care Mrs Le Page had been given, but they were not serious enough to have caused her death. He also said there had been inadequate documentation of Mrs Le Page's treatment in Southampton, and said that had led to certain choices being made. "Despite the failings in her care identified in my report, I am not of the opinion that they were the predominant cause of her death, and the outcome would on balance of probabilities have been the same even if full prophylaxis had been utilised," he said.
"If she had been diagnosed with leg or Pelvic vein DVT on [the 9th] and treated with full anticoagulation, this would have stopped further propagation and enlargement of the clot, but would not have prevented it embossing to the pulmonary circulation the same day. Only if an Inferior Vena Caval filter had been inserted would Mrs Le Page's life have been saved.
"However in the time available between complaint of symptoms to suggest DVT and her death, there would in my opinion gave been inadequate time to diagnose DVT, consult the neurosurgeons regarding treatment, arrange with a vascular radiologist to insert an IVC filter and successfully insert [it]."
The family told Judge Graeme McKerrell that they accepted Dr da Costa's report, and so he returned a verdict of death by natural causes.
He said the 20 month delay in this conclusion was regrettable, but had allowed the case to be thoroughly explored.
Pictured top: Mrs Le Page died at the PEH on the 9 June 2017.
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