Karl Dunstan

[REDACTED] – CEO Milton Keynes University Hospital

I am Tom OSBORNE, Senior Coroner for the coroner area of Milton Keynes

On 21 January 2025 I commenced an investigation into the death of Karl Fraser DUNSTAN aged 56. The investigation concluded at the end of the inquest on 23 June 2025. The conclusion of the inquest was that: Narrative conclusion The deceased died at Milton Keynes University Hospital on 14th January 2025 from a pulmonary embolism arising from a deep vein thrombosis. The opportunity to investigate and treat the pulmonary embolism was missed when the request for a CT pulmonary angiogram was declined without D-dimer testing and, when his clinical condition declined, was not met with emergency treatment for a pulmonary embolism. The missed opportunities more than minimally contributed to his death.

Karl Dunstan died at Milton Keynes University Hospital on 14th January 2025 from a pulmonary thromboembolism arising from a deep vein thrombosis. He had been admitted to the hospital the previous day with symptoms suggestive of a chest infection, but also with clinical features indicative of a pulmonary embolism, including shortage of breath, episodes of collapse and hypoxia. A request for a CT pulmonary angiogram was denied by the radiologist as it did not meet their criteria. There was a failure to perform a D-dimer test that if positive would have led to a CTPA that would have confirmed the pulmonary embolism. This would have resulted in thrombolysis being started when he collapsed.

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.  In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: That the investigation of a pulmonary embolism was not carried out in accordance with NICE guidance, and a request for a CT pulmonary angiogram by the consultant was rejected by the radiology department because it did not meet the threshold of the Wells score used by the Hospital and yet a D-dimer test was not completed, that if positive, would have resulted in a CTPA. The policy and procedure is in need of an urgent review.

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.