Coroner finds that former Detective Inspector died from massive internal haemorrhage due to anticoagulation medication, not Covid-19 as the family were told by the hospital
When Andy Kirby, a retired Detective Inspector, died in hospital on Christmas Eve in 2020, his family were told that – like so many others around that time - he had died from Covid-19.
However, Andy's family knew that he had had repeated Covid-19 tests in hospital that were negative, and felt that something was not right.
They requested that the coroner order a post-mortem, and this revealed that, in fact, he had died from a massive undiagnosed gastrointestinal bleed, and there was no evidence of Covid-19. This left the family with so many questions.
The coroner held a three-day inquest, and heard detailed evidence from various hospital witnesses, including four different consultants, and two independent experts (a general surgeon and a haematologist).
It was established that, after being admitted to hospital, Andy was treated for bilateral pneumonia and probable abdominal sepsis. However, a CT scan also revealed a pulmonary embolism (blood clot), for which he was given a therapeutic dose of anticoagulation (dalteparin).
The next day, Andy had signs of bleeding. There was blood in his urine, blood in his sputum and dried blood around his mouth. In addition, his haemoglobin level dropped significantly, blood urea level increased, and his blood pressure was extremely low (57/30). One doctor documented that Andy was in ‘hypovolemic shock’. All of this suggested that Andy was in a “general state of acquired coagulopathy with bleeding from two sites (urinary tract and lungs)”, the expert said. Andy’s treating consultant therefore decided to withhold any more anticoagulation due to bleeding.
However, the following day, Andy was reviewed by a different doctor who had stepped in to assist because the ward round had been delayed. She had not been involved in Andy’s care previously and decided to restart the anticoagulation to treat his PE. This was without carrying out repeat blood tests or considering the alternative option of an IVC filter to manage the PE.
Following this, Andy’s condition deteriorated and he died in the early hours of the morning on Christmas Eve. The coroner concluded that the acute gastrointestinal bleed “in all probability occurred due to the recommencement of the anticoagulation medication”.
Whilst nothing will bring Andy back, this case shows the importance of the inquest process in getting answers for families to help them get closure and come to terms with what happened.
The family was represented by Matthew Turner instructed by Caroline Murgatroyd of Hudgell Solicitors. Matthew is a specialist in both inquests and clinical negligence, so is well placed to represent families in inquests involving complex medical issues.
The Coroner was HM Assistant Coroner for Hull and the East Riding, Mr Ian Sprakes.
The other Interested Person was Hull University Teaching Hospitals NHS Trust.