Wexham Park Hospital trust reviews policy after 24-year-old's blood clot death

A coroner has urged an NHS trust to take action on its blood clot testing policy following the death of a young woman at Wexham Park Hospital in Slough. 

Ellen Mercer, 24, died from blood clots following nitrous oxide use when she was taken to Wexham Park - run by NHS Frimley Health trust - last year.

But she did not receive a test to identify if clots were present, despite being at the hospital for nearly a day.

A coroner’s prevention of future deaths report, made public this month, said, given the increasing length of time patients are waiting to receive care, changes in testing policy should be considered.

Senior coroner for Berkshire, Heidi Connor, said in the report: “I am concerned that policies may need to reflect the current reality on the ground.”

Ellen died in Wexham Park’s emergency department almost 24 hours after she arrived at the hospital via ambulance.

The coroner's report said her death was caused by blood clots as a result of immobility due to nitrous oxide use.

Ellen had reduced movement because of injuries to her legs from the nitrous oxide canisters she used.

Nitrous oxide (NOS), also known as laughing gas, was classified as a class C drug last year.

While receiving treatment at Wexham Park, she was not given a VTE assessment: a test to identify whether a person has developed - or is at risk of developing – blood clots.

A VTE assessment must be undertaken within 24 hours of a patient being admitted to hospital.

However, under existing policy, a patient is only considered admitted when they are transferred to a ward and not when they first present at hospital.

Ms Connor’s report says that long waiting times, combined with the lack of clarity over assessment times, could risk lives.

“Patients are unfortunately waiting increasingly longer times in emergency departments – not just in waiting areas, but also after being seen by clinical staff and waiting for admission to a ward or discharge from the hospital,” said Ms Connor.

She added: “If current policies require VTE risk assessment to take place within 24 hours, the point at which that 24-hour period starts is not sufficiently clear and does not take long waits in emergency departments into account."

The problem is likely to be a national concern, she continued.

A spokesperson from Frimley Health NHS trust said a review into VTE assessment policy was underway.

“Ellen’s death was a tragic loss and our hearts go out to her family, friends and loved ones,” the spokesperson said.

“At the coroner’s request, NHS England, NICE (National Institute of Health and Clinical Excellence) and Frimley Health are reviewing processes in relation to VTE assessment and we will be sending our response shortly – although the coroner concluded that performing the test on Ellen would sadly not have saved her life.”

The deadline for responses to the coroner’s report is 21 June.