A coroner is to write to the Chief Medical Officer highlighting the dangers of Deep Vein Thrombosis (DVT) - better known as blood clots - following the death of a Presbyterian minister who had broken a toe.
Mr Joe McCrisken made the remarks at the inquest into the death of Reverend Robert Alexander Campbell, of Tullybroom Road, Clogher who passed away last year, aged 46.
Known as Roy, the late minister of Clogher and Glenhoy Presbyterian Church in Co Tyrone had suffered a fractured toe on his left foot, which had caused him mobility issues in the weeks prior to his death.
Rev Campbell, who was married to Tonya and had a young son and daughter, was assessed at Tyrone County Hospital Accident & Emergency Department on May 10, 2017, and after diagnosis was placed in a plaster cast and provided with crutches.
At a later assessment on May 31, a decision was taken to proceed without surgery and treat the injury with six weeks of non-weight bearing - meaning the leg must not touch the floor and is not permitted to support any weight at all. This was to be followed by six weeks of protective weight bearing, in which some body weight may be supported by the affected leg.
But less than a week later, Rev Campbell passed away, with the cause of death primarily found to be pulmonary thromboembolism - a clot on the lung. Contributing factors were the associated injury and a clot in the left leg.
Mr McCrisken said he had spoken privately with Rev Campbell's relatives in advance of the inquest opening, and they had raised concerns as to why there had been no preventive action taken by physicians to address the potential for blood clots following the injury.
The coroner said: "I have been able to reassure the family all required protocols were followed and as a result a full inquest to formally hear from medical staff will not be necessary."
He found that all medical staff had adhered fully to the required procedures and the treatment was appropriate.
A risk assessment was conducted and it was recorded no thromboprophylaxis (anti-clotting medication) was required. The coroner said that Rev Campbell "did not present as at an elevated risk of a deep vein thrombosis and the proper care was provided".
He added: "It was difficult for the family to understand what had occurred and why.
"On review of the paperwork, I see absolutely no issue at all with care, and I have explained this to the family."
However, Mr McCrisken said he would write to the Chief Medical Officer, suggesting information is provided to health care staff in all situations, not just where risk is indicated such as age, obesity or other factors.
He said: "This death shows there may still be some risk. While I am satisfied Reverend Campbell was given good and accurate advice, I want to raise the issue with the Chief Medical Officer."
A lawyer conveyed the Western Health Trust's sympathies to Rev Campbell's family.