The coroner said Isaac would likely have survived if he had been admitted to hospital when his condition worsened and issued a Prevention of Future Deaths report.

His family, Neil and Louise Arrowsmith, criticized the care, saying staff did not follow processes or understand the virtual ward, and they reported the case to the Care Quality Commission with Enable Law potentially pursuing legal action.

The Trust’s apology also noted improvements to the electronic patient record system and a plan to bolster multidisciplinary reviews, with the Care Quality Commission reviewing the response.

The Care Quality Commission and the Trust are reviewing the case and the Prevention of Future Deaths report to determine further actions, while the family organized a fundraising campaign in Isaac’s memory for Scouts.

The coroner highlighted insufficient weighting of Isaac’s underlying blood disorder and clotting risk, and suggested the virtual ward did not operate effectively for his case.

An inquest concluded that mistakes in Isaac Arrowsmith’s care contributed to his death, including not being referred to the respiratory virtual ward and not being admitted when his condition deteriorated.

The 19-year-old, who had Haemoglobin Rainier disease, died on January 2 after collapsing from a pulmonary embolus and deep vein thrombosis, with the death deemed preventable by the inquest.

Internal hospital investigations had previously suggested the death was not preventable, but the inquest contradicted this, citing clear failings in recognizing and managing thrombotic risk and triage.

Before his death, Isaac returned to hospital on December 31 after coughing blood and was discharged with limited testing, with follow-up promised from the virtual ward within 48 hours.

East Cheshire NHS Trust apologized for the lapse in care and outlined steps including enhanced clinician education on misdiagnosis and thrombotic risk, changes to electronic patient records, and strengthened multidisciplinary review processes.

In December 2025 Isaac presented with chest pain and pneumonia symptoms, was discharged without tests to rule out pulmonary embolism, and later was told he would be supported by the respiratory virtual ward rather than admitted.

He developed chest pain and breathlessness, was diagnosed with pneumonia at Macclesfield District General Hospital, and returned with worse symptoms before again being discharged without pulmonary embolism testing.