Pete, who was 71, died on 22 October last year two months after undergoing an operation to remove his prostate, after being diagnosed with cancer in October 2014.
He was discharged two days afer the operation from Redditch’s Alexandra Hospital, but was readmitted with a urinary tract infection and died nine weeks later after his health deteriorated.
During a two-day-long inquest at Worcestershire Coroner’s Court, a jury heard blood-thinning drugs had been administered on two occasions when Pete was not in a suitable condition to receive them.
Consultant urologist Vincent Koo, who conducted an investigation into Pete’s death for Worcestershire Acute Hospitals NHS Trust, that he was given a substitute for his usual deep vein thrombosis medication until 1 September.
At this point his blood was thinner than the recommended level, but the information was not effectively communicated to other hospital staff, meaning the normal dose was given again, followed by another smaller dose the following day.
Mr Koo told the inquest: “It should have been stopped. All clinicians tried their best but we have learnt our lesson. It’s very easy to look back with a retrospective scope and say we should have done differently, but there is no ‘one shoe fits all’. As clinicians, we have to make difficult decisions about what is best for that specific patient.”
Asked by assistant coroner David Reid if the medication had played a part in Pete’s death, Mr Koo said it was a “contributing factor but not a direct sole cause”.
When readmitted, Pete was suffering from an infection and kidney dysfunction, which likely contributed to the formation of the hematoma, placing him at greater risk of developing further infection.
Despite two CT scans, a source of the internal bleed was not found, nor was it discovered during the post-mortem exam, and Mr Koo told the court t was likely caused by infection and stemmed from smaller blood vessels that failed to heal after his operation.
The Trust has since changed the way it records and displays blood thickness levels for patients who have recently received the same therapy as Pete did.
The jury recorded Pete’s medical cause of death as sepsis, caused by acute pyelonephritis and renal abscess.
Hematoma following prostate surgery and warfarin therapy for vein thrombosis were listed as secondary causes, with an overall verdict of ‘accidental death’.
Speaking after the result, Pete’s son Andy, 47, said: “My family is quite happy with the verdict and happy that these proceedings have finally come to a close so we can start moving on.
“Obviously there were some misgivings, but as a family we’re happy that the trust has made these changes to prevent another family going the same agony and stress we have. That’s what my father would have wanted.”