A young university student tragically lost her life to a blood clot after spending 24 hours in the Accident and Emergency department of Wexham Park Hospital without getting a formal clot risk assessment.

Ellen Mercer, 24, from Gerrards Cross was rushed to the hospital on February 9 last year after losing feeling in her legs.

An inquest revealed her cause of death to be a clot, the result of nitrous oxide use and immobility.

Following these revelations, a coroner has expressed concern over the unclear NHS policy regarding blood clot risk assessments in the emergency department.

Heidi Connor, Coroner for Berkshire, has highlighted the urgent need to address this inadequacy in healthcare practice.

She pointed out that increased incapacity and prolonged wait times in emergency departments were not being considered while conducting such risk assessments.

She said: "The starting point for her deterioration and hospital attendance was her mental health and her use of nitrous oxide.

"The canisters she used had caused injuries to her legs and decreased her mobility."

The fact that laughing gas, or nitrous oxide, played a role in the formation of the blood clot leading to Ellen’s death is a grim reminder of its risks when used irresponsibly.

The substance induces short-lived euphoric feelings and has effects such as dizziness, laughter, sound distortions, and even hallucinations.

Risks associated with its use include unconsciousness or death due to reduced oxygen availability, especially when consumed heavily.

As per Mrs Connor: "Death was caused by nitrous oxide use and immobility which led to the development of pulmonary emboli".

It's noteworthy that nitrous oxide was declared a Class C drug last year due to its potential dangers, but the law was not in effect at the time of Ellen's death.

In her report outlining preventive measures to avoid recurrence of such tragedies, Mrs.

Connor has written to NHS England stressing the importance of timely Venous Thromboembolism (VTE) risk assessments.

VTE refers to a condition resulting from blood clots formed in a vein.

She pointed out that the lack of specific guidelines about when the 24-hour period for risk assessment should start could delay a significant medical intervention.

The policy currently in force in Frimley Health NHS Trust suggests the commencement of this period only after the patient’s admission into the hospital, possibly hours after their arrival at the emergency department.

Mrs Connor stated: "The policy as currently drafted implies that VTE risk assessment is essentially not relevant for emergency department patients.

"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.

"I am concerned that policies may need to reflect the current reality on the ground."

A previous inquest had concluded that a timely VTE risk assessment could have potentially detected Ellen's heightened risk of developing a blood clot.

The various organisations Mrs Connor addressed have 56 days to respond to her findings.

While changes to health service policies are awaited, the tragic loss has left Ellen's friends and family mourning a "truly beautiful and gentle soul".