Recurring concern

Inadequate thromboprophylaxis for patients at risk of venous thromboembolism

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First reported 13 Feb 2013•Latest report 4 Jun 2024

Definition

What this concern includes

Includes failures of assessment, prescribing, arrangement, communication, implementation, delivery or monitoring that are specifically dedicated to preventing venous thromboembolism, including the anchor's failure to obtain and clarify discharge thromboprophylaxis requirements.

Not included

Excludes generic failures to obtain, transfer or document information unless they are specifically tied to a thromboprophylaxis decision or requirement.
Excludes unrelated medication, discharge-planning or clinical-assessment failures that do not concern venous thromboembolism prevention.
Excludes thrombosis outcomes or general immobility risks without an identified thromboprophylaxis control failure.

Reports: 27
Individual concerns: 35
Date range: 2013–2024
Stated actions: 50

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care6

National Institute for Health and Care Excellence4

East Lancashire Hospitals NHS Trust2

East London NHS Foundation Trust2

Lancashire Teaching Hospitals NHS Foundation Trust2

NHS England2

Sussex Partnership NHS Foundation Trust2

University Hospitals Sussex NHS Foundation Trust2

Worcestershire Acute Hospitals NHS Trust2

Barts Health NHS Trust1

Bradford Teaching Hospitals NHS Foundation Trust1

Brunswick Ward at Lindridge1

Doncaster Royal Infirmary1

East and North Hertfordshire Teaching NHS Trust1

Frome Care Village1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

4 Jun2024
Worcestershire
Concerns raised1
1. Lack of a system to ensure that mechanical thromboprophylaxis instructions are carried out
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Deliver weekly teaching on mechanical prophylaxis and reinforce signing prescription charts to confirm prophylaxis is in place.
  Stated by Worcestershire Acute Hospitals NHS TrustStated planned
2. Action
  Include prescription-chart checks in matron audits to verify prophylaxis prescriptions are signed as in place.
  Stated by Worcestershire Acute Hospitals NHS TrustStated planned
3. Action
  Implement mechanical prophylaxis documentation on the electronic patient prescribing and administration system.
  Stated by Worcestershire Acute Hospitals NHS TrustStated planned
AI-generated summary

Susan Lynne EDWARDS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Susan Edwards died in hospital on 7 October 2023 after a sudden deterioration, with post-mortem examination establishing that the cause was a large pulmonary embolus. The report raised concerns that an instruction for mechanical thromboprophylaxis was not carried out and that Worcestershire Royal Hospital had no apparent system to ensure such instructions were followed, potentially putting patients at risk.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a system to ensure that mechanical thromboprophylaxis instructions are carried out
Wider context from the report
“1) On 19 September 2023 a Venous Thromboembolism Risk Assessment made clear that Mrs. Edwards should be provided with mechanical thromboprophylaxis. This instruction was not entered on Mrs. Edwards’ anticoagulation drug card, and Mrs. Edwards was not provided with any form of mechanical thromboprophylaxis between that date and her death 18 days later on 7 October 2023. No nurse or reviewing doctor picked up on this omission. Although I was satisfied that, in this case, the provision of mechanical thromboprophylaxis would probably not have prevented Mrs. Edwards’ death, I am concerned that: (a) no system appears to be in place at Worcestershire Royal Hospital to ensure that such an instruction is carried out; and (b) as long as that remains the case, the lives of patients who require thromboprophylaxis during a hospital admission may be put at risk. ”
Source location
Susan Lynne EDWARDS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver weekly teaching on mechanical prophylaxis and reinforce signing prescription charts to confirm prophylaxis is in place.

Verbatim wording from the response
“1. We have focussed on educating our staff in order to provide clear instructions around this area and will implement the following:”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 7 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Include prescription-chart checks in matron audits to verify prophylaxis prescriptions are signed as in place.

Verbatim wording from the response
“2. Monitoring:”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 7 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement mechanical prophylaxis documentation on the electronic patient prescribing and administration system.

Verbatim wording from the response
“3. Long term plan is this will be on the electronic patient medical prescribing / administration system.”

Source location
Response from Worcestershire Acute Hospitals NHS Trust
Page 2 · response
Published 7 June 2024
Open published response
15 Jan2024
Manchester South
Concerns raised2
1. Lack of clarity on VTE prophylaxis for patients who are both bariatric and neurosurgical
2. Failure to follow and understand the VTE policy for discharge risk reduction
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  Lancashire Teaching Hospitals NHS Foundation Trust is the appropriate organisation to respond to concerns one to seven.
  Stated by NHS EnglandRedirects responsibility
1. Position
  Concerns about differing prophylaxis approaches should be referred to NICE, which produces the relevant clinical guidelines.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Rhys Lennon Hill · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Rhys Lennon Hill underwent spinal surgery and was discharged from Royal Preston Hospital on 30 January 2023. He collapsed at home on 9 February 2023 and attempts to resuscitate him were unsuccessful; a post-mortem examination found that he died from a pulmonary embolus due to a deep vein thrombosis. The principal concerns included failure to escalate his refusal of Dalteparin or assess the associated risk, failure to provide required VTE information at discharge, and wider problems with communication, documentation, medication reconciliation, and discharge processes.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clarity on VTE prophylaxis for patients who are both bariatric and neurosurgical
Wider context from the report
“8. The VTE policy of the trust is based on the NICE guidance. The inquest identified that there is a difference in approach on the use of prophylaxis for a surgical bariatric patient and a neuro surgical patient. Where there is a bariatric patient who is a neuro surgical patient there does not appear to be any clarity on how the challenges should be approached to reduce the risk of VTE as far as possible. ”
Source location
Rhys Lennon Hill · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to follow and understand the VTE policy for discharge risk reduction
Wider context from the report
“3. The VTE policy was not fully followed and there was evidence that there was limited understanding by staff of precisely what the trust policy required in relation to reducing the risk at discharge of VTE; ”
Source location
Rhys Lennon Hill · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Lancashire Teaching Hospitals NHS Foundation Trust is the appropriate organisation to respond to concerns one to seven.

Verbatim wording from the response
“This response focuses on the issues raised in your Report within the remit of NHS England national policy and programmes. Concern numbers one to seven in your Report fall under the remit of Lancashire Teaching Hospitals NHS Foundation Trust. I note that you have also addressed your Report to the Trust, who are the appropriate organisation to respond. NHS England has requested to be sighted on this and will carefully consider their response to the coroner. My regional Quality colleagues within the North West have been engaging with Lancashire and South Cumbria Integrated Care Board (ICB) to seek assurance for the local concerns raised.”

Source location
Response from NHS England
Page 1 · response
Published 19 January 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Concerns about differing prophylaxis approaches should be referred to NICE, which produces the relevant clinical guidelines.

Verbatim wording from the response
“Concern number eight in your report raises concerns that there is a difference in approach on the use of prophylaxis for a surgical bariatric patient and a neurosurgical patient. You raised the concern that where there is a bariatric patient who has also undergone neurosurgery there is a lack of clarity on how to reduce the chances of venous thromboembolism (VTE) occurring. As your Report notes, the National Institute for Health and Care Excellence (NICE) produce the relevant clinical guidelines [NG89] for reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism and the Quality Standard for Venous thromboembolism in adults [QS2011]. You may also therefore wish to refer your concerns to NICE.”

Source location
Response from NHS England
Page 1 · response
Published 19 January 2024
Open published response
28 Nov2023
West Sussex, Brighton and Hove
Concerns raised1
1. Lack of venous thromboembolism risk assessment for hospital patients who are not admitted
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Develop a Trust thromboprophylaxis policy for ambulatory trauma patients discharged from the Emergency Department.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
AI-generated summary

Ann Dorothy PEARCE · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ann Dorothy Pearce was discharged from hospital on 28 March 2022 after treatment for a tibial spine fracture, having been immobilised in a brace and only partially weight bearing. No venous thromboembolism assessment was undertaken during her admission or on discharge, and she died from a massive pulmonary embolism on 1 April 2022; the inquest also identified that the relevant policy did not cover patients attending hospital without being admitted.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of venous thromboembolism risk assessment for hospital patients who are not admitted
Wider context from the report
“Evidence at the inquest revealed that the Venous Thromboembolism Prevention Policy of University Hospitals Sussex NHS Foundation Trust version 1.4 did not make provision for assessment of risk to patients who attended hospital but were not admitted. There was no evidence of any other policy or procedure which did so. ”
Source location
Ann Dorothy PEARCE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a Trust thromboprophylaxis policy for ambulatory trauma patients discharged from the Emergency Department.

Verbatim wording from the response
“We have developed a Trust policy for Thromboprophylaxis in Ambulatory Trauma Patients discharged from the Emergency Department.”

Source location
Response from University Hospitals Sussex NHS Foundation Trust
Page 1 · response
Published 1 December 2023
Open published response
22 Nov2023
Cornwall and Isles of Scilly
Concerns raised1
1. NICE guidance not reflecting the use of LMWH with non-TED-stocking VTE prevention products
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Share the coroner’s report with the guideline surveillance team for consideration during future guideline review.
  Stated by National Institute for Health and Care ExcellenceStated completed
AI-generated summary

David John Lewsey · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

David John Lewsey, aged 68, developed a pulmonary embolus following a left knee replacement and died after collapsing at home on 15 December 2022. Concerns included that severe side pain reported to reception staff was not passed to the advanced nurse practitioner, and that the pain’s location was not explored further. The report also raised whether staff training should better address chest or abdominal pain in recently immobilised post-operative patients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
NICE guidance not reflecting the use of LMWH with non-TED-stocking VTE prevention products
Wider context from the report
“The relevant NICE guidance may need to be updated to reflect the use of LMWH with products that assist with VTE prevention other than TED stockings. ”
Source location
David John Lewsey · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share the coroner’s report with the guideline surveillance team for consideration during future guideline review.

Verbatim wording from the response
“Your report has been shared with our guideline surveillance team for further consideration when the guideline is reviewed.”

Source location
Response from National Institute for Health and Care Excellence
Page 2 · response
Published 28 November 2023
Open published response
7 Nov2023
Somerset
Concerns raised2
1. Absence of an active DVT policy
2. Failure to obtain and clarify discharging-hospital information about care needs and thromboprophylaxis
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Irene Joy White · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Irene Joy White, who had dementia and became immobile after a fall and hip-fracture surgery, was discharged to a nursing home without further thromboprophylaxis and was not mobilised beyond regular repositioning. She died of a pulmonary embolism, and concerns were raised about the nursing home's failure to identify and manage her DVT risk, including the absence of a DVT policy.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Absence of an active DVT policy
Wider context from the report
“I am concerned following the evidence presented to the Inquest that: (i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet: (a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan; (b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT; (c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT (ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk. I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken. Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard. ”
Source location
Irene Joy White · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to obtain and clarify discharging-hospital information about care needs and thromboprophylaxis
Wider context from the report
“I am concerned following the evidence presented to the Inquest that: (i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet: (a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan; (b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT; (c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT (ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk. I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken. Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard. ”
Source location
Irene Joy White · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Oct2023
Worcestershire
Concerns raised1
1. Lack of clarity about VTE risk-assessment responsibilities at hospital-to-community discharge
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review the guideline for updates covering continuation of VTE prophylaxis and anticoagulation after discharge to community settings.
  Stated by National Institute for Health and Care ExcellenceStated planned
2. Action
  Consider providing implementation support on VTE risk assessments and discharge planning, focusing on anticoagulation.
  Stated by National Institute for Health and Care ExcellenceStated planned
AI-generated summary

ANDREW ETLERED NICHOLS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Andrew Nichols developed acute disseminated encephalomyelitis after vaccination and spent over a year receiving hospital and neuro-rehabilitation care. His anticoagulation medication was not continued when he was discharged to community care, and he subsequently died from deep vein thrombosis and pulmonary embolism. The principal concerns were unclear responsibility for venous thromboembolism risk assessments between hospitals and community organisations, and inadequate pathways for organisations to identify relevant NICE guidance.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clarity about VTE risk-assessment responsibilities at hospital-to-community discharge
Wider context from the report
“1) There seems to be a lack of clarity amongst health and care professionals (certainly those who gave evidence at this inquest) as to whether community organisations receiving patients following discharge from hospital (such as neurorehabilitation centres and care homes) should, as a routine part of their responsibilities, be performing VTE risk assessments. I was referred to NICE Guidance 89 (Venous thromboembolism in Over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism – published March 2018, updated August 2019), which deals with VTE assessment and procedure for hospital patients, but there is no reference in this guidance to assessments in the community. There is reference in the guidance to patients about to be discharged (paragraph 1.2), but this appears to cover the practicalities of situations where a firm decision has already been made by hospital clinicians that anticoagulation will continue. I am concerned that hospital clinicians may not be routinely performing VTE assessments as part of discharge planning, on the basis that they believe such assessment will occur in the community placement. However, it is unclear whether (and, based on evidence heard at the inquest, unlikely that) many community organisations are performing such assessments, and instead most will be relying on hospitals to do this. I am concerned that, as a result, as happened to Andrew, some patients will not have their VTE risk considered when they move from being an in-patient to residing in a community setting. Consideration could be given to making the NICE guidance (NG 89) clearer in respect of the respective responsibilities placed on hospital and community organisations, when a patient is to be discharged from one to the other. Consideration could also be given to the desirability of separate guidance covering VTE risk assessment in community settings, and the potential importance of this to certain groups of patients, particularly those who are immobile and requiring long-term community care. ”
Source location
ANDREW ETLERED NICHOLS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the guideline for updates covering continuation of VTE prophylaxis and anticoagulation after discharge to community settings.

Verbatim wording from the response
“To address this we propose to review the guideline to see if it can be updated to cover the issue of continuing VTE prophylaxis on discharge so that inpatient anticoagulation prescriptions for VTE prophylaxis are converted to ongoing anticoagulation where required, ensuring that the intention cannot be misinterpreted.”

Source location
Response from National Institute for Health and Care Excellence
Page 1 · response
Published 6 November 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Consider providing implementation support on VTE risk assessments and discharge planning, focusing on anticoagulation.

Verbatim wording from the response
“To further support the implementation of this guideline NICE’s implementation support team will consider the delivery of support on VTE risk assessments and discharge planning with a specific focus on anticoagulation.”

Source location
Response from National Institute for Health and Care Excellence
Page 1 · response
Published 6 November 2023
Open published response
7 Sep2023
East London
Concerns raised1
1. Failure to withhold low molecular weight heparin VTE prophylaxis in the presence of active bleeding
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sultana Choudhury · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Sultana Choudhury died in hospital on 17 December 2022 after suffering a renal haemorrhage following a renal biopsy, leading to hypovolaemia and cardiac arrest. The concerns included failure to diagnose the ongoing haemorrhage, administration of VTE prophylaxis despite haematuria, and inadequate monitoring during her admission.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to withhold low molecular weight heparin VTE prophylaxis in the presence of active bleeding
Wider context from the report
“2. The clinical decision to administer VTE prophylaxis in the form of low molecular weight heparin on admission to a patient with a patent bleed, evidenced by haematuria. ”
Source location
Sultana Choudhury · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 May2023
Cornwall and Isles of Scilly
Concerns raised3
1. Failure to provide risk-appropriate thrombosis prophylaxis after elective knee replacement
2. Failure to ensure clinicians access accurate thrombosis prophylaxis guidance
3. Routine prescription of aspirin to high-risk patients regardless of prophylaxis guidance
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Conduct mandatory annual audits of DVT prophylaxis prescribing for elective hip and knee replacement surgery.
  Stated by Royal Cornwall Hospitals NHS TrustStated completed
2. Action
  Scrutinise and ratify the Thrombosis Prevention and Anticoagulation Policy in its current form through the steering group.
  Stated by Royal Cornwall Hospitals NHS TrustStated completed
3. Action
  Review the Thrombosis and Anticoagulation policy arrangements through a larger workstream to improve accessibility and remove ambiguity.
  Stated by Royal Cornwall Hospitals NHS TrustStated planned
1. Action
  Audit the ten most recently uploaded document-library policies within three months to verify that the correct approval process was followed.
  Stated by Royal Cornwall Hospitals NHS TrustStated planned
Respondent positions 2
1. Position
  Existing NICE-based Trust protocols, risk assessment, and mandatory audits are considered sufficient to ensure correct elective knee replacement DVT prophylaxis.
  Stated by Royal Cornwall Hospitals NHS TrustExisting arrangements considered sufficient
1. Position
  TPAS considered the policy’s acknowledged ambiguity insufficiently risky to warrant removal and ratified the current policy pending broader review.
  Stated by Royal Cornwall Hospitals NHS TrustExisting arrangements considered sufficient
AI-generated summary

Julie Louise Hancock · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Julie Louise Hancock underwent a right total knee replacement on 2 March 2022, was discharged on 5 March 2022, and died at home on 28 March 2022. Her post-mortem cause of death was pulmonary embolus due to deep vein thrombosis, with immobility following the knee replacement. The concerns included apparent prescription of low-risk thrombosis prophylaxis despite her being assessed as high risk, an unidentified doctor’s prescription of dalteparin that was stopped after one dose, and possible discrepancies between summary and full thrombosis-prevention guidance.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide risk-appropriate thrombosis prophylaxis after elective knee replacement
Wider context from the report
“I enclose the bundle of evidence. At pp A32-A54, you will find what I am told is the Trust’s Guideline Summary for Thrombosis Prevention and Anticoagulation. At p42, following elective knee replacement, it is suggested clinicians may choose any one of Aspirin ████████ for 14 days LMWH for 14 days and anti-embolism stockings Rivaroxaban ████████ once daily for 14 days As matters of fact, I am told Mrs Hancock was prescribed 14 days of aspirin, an apparent error, one unidentified doctor also prescribed Dalteparin which was stopped after a single dose. It is of concern that the doctor cannot be identified and I have no record of the decision-making. At C32, you will find the Trust’s full guidance for drug prophylaxis following elective knee replacement which is taken from its Thrombosis Prevention and Anticoagulation Policy v9.0 dated Feb 2022. It provides: Low risk – Aspirin ████████ daily for 14 days High Risk – Rivaroxaban ████████ daily for 14 days or Dalteparin or Enoxaparin for 28 days plus stockings (until discharge.) ████████ had not seen the full guidance previously despite it having been published for over a year which, as a consultant orthopaedic surgeon, is of concern in itself. █ further said that Mrs Hancock was high risk yet she appears to have been given prophylaxis for a low risk patient because the summary guidelines appear not to reflect accurately the full guidance. ████████, as I understood ███, said that it had been █ practice to prescribe aspirin to all high-risk patients since (at least) February 2022. This raises the question of whether other patients have died from a PE or DVT because of wrongly prescribed prophylaxis that have not been reported to this Office. You will need to consider the position. I have only considered the situation as it came before me, namely, for an elective knee replacement. As I understand the anticoagulation policy will have a much wider reach than that there is an obvious need to consider the implications across all the Trust’s services. ”
Source location
Julie Louise Hancock · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure clinicians access accurate thrombosis prophylaxis guidance
Wider context from the report
“I enclose the bundle of evidence. At pp A32-A54, you will find what I am told is the Trust’s Guideline Summary for Thrombosis Prevention and Anticoagulation. At p42, following elective knee replacement, it is suggested clinicians may choose any one of Aspirin ████████ for 14 days LMWH for 14 days and anti-embolism stockings Rivaroxaban ████████ once daily for 14 days As matters of fact, I am told Mrs Hancock was prescribed 14 days of aspirin, an apparent error, one unidentified doctor also prescribed Dalteparin which was stopped after a single dose. It is of concern that the doctor cannot be identified and I have no record of the decision-making. At C32, you will find the Trust’s full guidance for drug prophylaxis following elective knee replacement which is taken from its Thrombosis Prevention and Anticoagulation Policy v9.0 dated Feb 2022. It provides: Low risk – Aspirin ████████ daily for 14 days High Risk – Rivaroxaban ████████ daily for 14 days or Dalteparin or Enoxaparin for 28 days plus stockings (until discharge.) ████████ had not seen the full guidance previously despite it having been published for over a year which, as a consultant orthopaedic surgeon, is of concern in itself. █ further said that Mrs Hancock was high risk yet she appears to have been given prophylaxis for a low risk patient because the summary guidelines appear not to reflect accurately the full guidance. ████████, as I understood ███, said that it had been █ practice to prescribe aspirin to all high-risk patients since (at least) February 2022. This raises the question of whether other patients have died from a PE or DVT because of wrongly prescribed prophylaxis that have not been reported to this Office. You will need to consider the position. I have only considered the situation as it came before me, namely, for an elective knee replacement. As I understand the anticoagulation policy will have a much wider reach than that there is an obvious need to consider the implications across all the Trust’s services. ”
Source location
Julie Louise Hancock · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Routine prescription of aspirin to high-risk patients regardless of prophylaxis guidance
Wider context from the report
“I enclose the bundle of evidence. At pp A32-A54, you will find what I am told is the Trust’s Guideline Summary for Thrombosis Prevention and Anticoagulation. At p42, following elective knee replacement, it is suggested clinicians may choose any one of Aspirin ████████ for 14 days LMWH for 14 days and anti-embolism stockings Rivaroxaban ████████ once daily for 14 days As matters of fact, I am told Mrs Hancock was prescribed 14 days of aspirin, an apparent error, one unidentified doctor also prescribed Dalteparin which was stopped after a single dose. It is of concern that the doctor cannot be identified and I have no record of the decision-making. At C32, you will find the Trust’s full guidance for drug prophylaxis following elective knee replacement which is taken from its Thrombosis Prevention and Anticoagulation Policy v9.0 dated Feb 2022. It provides: Low risk – Aspirin ████████ daily for 14 days High Risk – Rivaroxaban ████████ daily for 14 days or Dalteparin or Enoxaparin for 28 days plus stockings (until discharge.) ████████ had not seen the full guidance previously despite it having been published for over a year which, as a consultant orthopaedic surgeon, is of concern in itself. █ further said that Mrs Hancock was high risk yet she appears to have been given prophylaxis for a low risk patient because the summary guidelines appear not to reflect accurately the full guidance. ████████, as I understood ███, said that it had been █ practice to prescribe aspirin to all high-risk patients since (at least) February 2022. This raises the question of whether other patients have died from a PE or DVT because of wrongly prescribed prophylaxis that have not been reported to this Office. You will need to consider the position. I have only considered the situation as it came before me, namely, for an elective knee replacement. As I understand the anticoagulation policy will have a much wider reach than that there is an obvious need to consider the implications across all the Trust’s services. ”
Source location
Julie Louise Hancock · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct mandatory annual audits of DVT prophylaxis prescribing for elective hip and knee replacement surgery.

Verbatim wording from the response
“Mrs Hancock had a DVT risk assessment prior to surgery. The Trust followed the NICE and RCHT elective knee replacement guidance and we have a standardised trust protocol based on these NICE Guidelines which was followed. Mrs Hancock has the correct prophylaxis prescribed. The orthopaedic surgeon who operated on Mrs Hancock is the orthopaedic audit lead and has been since 2011. Mandatory annual audit of DVT prophylaxis have been carried out and the Trust has been 100% compliant in correctly prescribing DVT prophylaxis in elective hip and knee replacement surgery.”

Source location
Response from Royal Cornwall Hospitals NHS Trust
Page 5 · response
Published 19 May 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Scrutinise and ratify the Thrombosis Prevention and Anticoagulation Policy in its current form through the steering group.

Verbatim wording from the response
“We can advise the Policy referenced at the part heard inquest of Mrs Hancock, Thrombosis Prevention & Anticoagulation Policy V9 dated February 2022 has ambiguity with regard how it presents local interpretation of NICE Guidelines on orthopaedic thromboprophylaxis. This policy had been refreshed in January 2022 by the VTE practitioner who has since retired. This policy did not go through the appropriate sub board groups for scrutiny, review and sign off. It has since been scrutinised by the Thrombosis Prevention and Anticoagulation Steering Group (TPAS; meeting 20th June 2023) who are satisfied that the acknowledged ambiguity in a single section of the document does not pose a greater risk to our patient population than removal of this guideline, which covers every inpatient specialty, would pose to many patients.”

Source location
Response from Royal Cornwall Hospitals NHS Trust
Page 5 · response
Published 19 May 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the Thrombosis and Anticoagulation policy arrangements through a larger workstream to improve accessibility and remove ambiguity.

Verbatim wording from the response
“On this basis TPAS have ratified the document in its current form with the understanding that it will be reviewed as part of a larger workstream to make the RCHT Thrombosis and Anticoagulation policy offerings more accessible and without ambiguity.”

Source location
Response from Royal Cornwall Hospitals NHS Trust
Page 5 · response
Published 19 May 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit the ten most recently uploaded document-library policies within three months to verify that the correct approval process was followed.

Verbatim wording from the response
“It is anticipated that this policy will be separated into smaller, digestible policies (e.g. Management of Suspected/confirmed VTE; Prophylaxis for medical and/or surgical patients; Elective Orthopaedics) This updated policy/policies will then go through the appropriate channels and groups (TPAS, Medicines Practice Committee, full engagement with Care Group and Clinical Directors, Clinical Effectiveness Group, Policy Review Group and Quality Assurance Committee) before formal sign off and before it can be uploaded onto our documents library. We will be more than happy to share copies any updated policy/policies when they have been through scrutiny and sign off.”

Source location
Response from Royal Cornwall Hospitals NHS Trust
Page 5 · response
Published 19 May 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing NICE-based Trust protocols, risk assessment, and mandatory audits are considered sufficient to ensure correct elective knee replacement DVT prophylaxis.

Verbatim wording from the response
“Mrs Hancock had a DVT risk assessment prior to surgery. The Trust followed the NICE and RCHT elective knee replacement guidance and we have a standardised trust protocol based on these NICE Guidelines which was followed. Mrs Hancock has the correct prophylaxis prescribed. The orthopaedic surgeon who operated on Mrs Hancock is the orthopaedic audit lead and has been since 2011. Mandatory annual audit of DVT prophylaxis have been carried out and the Trust has been 100% compliant in correctly prescribing DVT prophylaxis in elective hip and knee replacement surgery.”

Source location
Response from Royal Cornwall Hospitals NHS Trust
Page 5 · response
Published 19 May 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
TPAS considered the policy’s acknowledged ambiguity insufficiently risky to warrant removal and ratified the current policy pending broader review.

Verbatim wording from the response
“We can advise the Policy referenced at the part heard inquest of Mrs Hancock, Thrombosis Prevention & Anticoagulation Policy V9 dated February 2022 has ambiguity with regard how it presents local interpretation of NICE Guidelines on orthopaedic thromboprophylaxis. This policy had been refreshed in January 2022 by the VTE practitioner who has since retired. This policy did not go through the appropriate sub board groups for scrutiny, review and sign off. It has since been scrutinised by the Thrombosis Prevention and Anticoagulation Steering Group (TPAS; meeting 20th June 2023) who are satisfied that the acknowledged ambiguity in a single section of the document does not pose a greater risk to our patient population than removal of this guideline, which covers every inpatient specialty, would pose to many patients.”

Source location
Response from Royal Cornwall Hospitals NHS Trust
Page 5 · response
Published 19 May 2023
Open published response
20 Jan2023
East London
Concerns raised1
1. Failure to assess inpatient patients for venous thromboembolism risk
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Review the Trust’s VTE policy.
  Stated by East London NHS Foundation TrustStated planned
2. Action
  Disseminate a VTE screening and assessment clinical alert across the Trust.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Add VTE assessment information to new-doctor induction and the junior doctors’ handbook.
  Stated by East London NHS Foundation TrustStated completed
1. Action
  Add antipsychotic medication as a consideration in the VTE assessment tool.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Include VTE risk in the monthly physical health training programme.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Trial Power BI and use it to monitor compliance with VTE risk assessments.
  Stated by East London NHS Foundation TrustStated in progress
4. Action
  Employ an Advanced Clinical Practitioner as Consultant Nurse in Physical Health to review in-patient physical health and address concerns in daily safety huddles.
  Stated by East London NHS Foundation TrustStated completed
5. Action
  Add RiO pop-up reminders prompting VTE risk assessment when patients’ presentations change.
  Stated by East London NHS Foundation TrustStated completed
AI-generated summary

Sophia Ayuk · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Sophia Ayuk, who had treatment-resistant schizophrenia and was an inpatient, became motionless and unresponsive on 18 March 2022, later deteriorated and died despite resuscitation. The inquest narrative attributed her death to a pulmonary embolism following a deep vein thrombosis, and recorded that she had not taken food or drink for at least two days. The principal concerns were that VTE risk was not assessed during either period of inpatient care and that food and fluid intake monitoring was not adequately followed.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to assess inpatient patients for venous thromboembolism risk
Wider context from the report
“1. At no time during the two periods of Ms Ayuk’s inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy. ”
Source location
Sophia Ayuk · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the Trust’s VTE policy.

Verbatim wording from the response
“I understand that you heard oral evidence at inquest that the Trust proposed the following actions to ensure that VTE risk assessments are undertaken in accordance with the Trust’s policy and best clinical practice:”

Source location
Response from East London NHS Foundation Trust
Page 1 · response
Published 25 January 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Disseminate a VTE screening and assessment clinical alert across the Trust.

Verbatim wording from the response
“2) A VTE Screening and Assessment Clinical Alert was disseminated across the Trust;”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 25 January 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Add VTE assessment information to new-doctor induction and the junior doctors’ handbook.

Verbatim wording from the response
“3) Changes were made to the new doctors’ induction and junior doctors handbook to include information on VTE assessments;”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 25 January 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Add antipsychotic medication as a consideration in the VTE assessment tool.

Verbatim wording from the response
“4) Anti-psychotic medication has been added as a consideration on the Trust’s VTE assessment tool;”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 25 January 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Include VTE risk in the monthly physical health training programme.

Verbatim wording from the response
“5) The Trust’s monthly two day physical health training programme now includes a session on VTE risk; and”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 25 January 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Trial Power BI and use it to monitor compliance with VTE risk assessments.

Verbatim wording from the response
“7) The Trust has been trialling Power BI (a data analytics tool) in order to monitor compliance with VTE risk assessments.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 25 January 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Employ an Advanced Clinical Practitioner as Consultant Nurse in Physical Health to review in-patient physical health and address concerns in daily safety huddles.

Verbatim wording from the response
“1) An Advanced Clinical Practitioner (ACP) has started in the role of Consultant Nurse in Physical Health at NCFMH. She reviews physical health on the in-patient wards. If she has concerns about the physical health of in-patients, including around VTE assessments, she addresses them with staff during daily, morning safety huddles.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 25 January 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Add RiO pop-up reminders prompting VTE risk assessment when patients’ presentations change.

Verbatim wording from the response
“2) The Trust’s electronic medical records system (RiO) was updated to include a pop-up reminder to seek a VTE risk assessment if someone’s presentation changes every time nurses update the Observations and Measurements Form.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 25 January 2023
Open published response
12 Sep2022
East London
Concerns raised1
1. Failure to assess inpatients for venous thromboembolism risk
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Undertake VTE assessments for all Cazaubon Ward admissions and audit completion weekly.
  Stated by East London NHS Foundation TrustStated in progress
2. Action
  Request an automated reporting-system update to enable ward-level VTE screening reports.
  Stated by East London NHS Foundation TrustStated planned
3. Action
  Amend physical-health policy to require admission VTE screening and correct RiO recording.
  Stated by East London NHS Foundation TrustStated planned
1. Action
  Amend nurses’ physical-health assessment to include VTE screening and complete screens through weekly audit processes.
  Stated by East London NHS Foundation TrustStated in progress
AI-generated summary

Delina Etienne · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Delina Etienne, who had schizo-affective disorder and was an inpatient receiving treatment, was found unresponsive in bed on 7 May 2021 and was declared deceased at the scene. The report identifies concerns about the chaotic response to her cardiac arrest, including failure to follow resuscitation procedures and an erroneous assumption that a DNACPR order was in place. It also identifies concerns about failures to escalate raised blood pressure and chest pain, assess VTE risk, and disclose the resuscitation error.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to assess inpatients for venous thromboembolism risk
Wider context from the report
“3. At no time during the two periods of Mrs Etienne’s inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy. ”
Source location
Delina Etienne · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Undertake VTE assessments for all Cazaubon Ward admissions and audit completion weekly.

Verbatim wording from the response
“All patients have a VTE assessment undertaken on admission to Cazaubon Ward. This was audited on 03.11.22 and will continue to be audited weekly. A request has been made to have the Trust’s automated reporting system updated to facilitate the ability to run a report on each wards VTE screening assessments.”

Source location
Response from East London NHS Foundation Trust
Page 3 · response
Published 5 October 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Request an automated reporting-system update to enable ward-level VTE screening reports.

Verbatim wording from the response
“All patients have a VTE assessment undertaken on admission to Cazaubon Ward. This was audited on 03.11.22 and will continue to be audited weekly. A request has been made to have the Trust’s automated reporting system updated to facilitate the ability to run a report on each wards VTE screening assessments.”

Source location
Response from East London NHS Foundation Trust
Page 3 · response
Published 5 October 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Amend physical-health policy to require admission VTE screening and correct RiO recording.

Verbatim wording from the response
“The author of the Trust policy for physical healthcare will amend the policy to emphasise that all patients need to have a VTE risk screening assessment undertaken on admission and the correct procedure for recording this in RiO.”

Source location
Response from East London NHS Foundation Trust
Page 3 · response
Published 5 October 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Amend nurses’ physical-health assessment to include VTE screening and complete screens through weekly audit processes.

Verbatim wording from the response
“The nurses’ physical health assessment is being amended to include a VTE screening assessment which would require a medical assessment to be completed if a risk was identified. Once this has been amended Cazaubon wards nursing staff will complete a screen for each patient as part of the wards weekly audit programme.”

Source location
Response from East London NHS Foundation Trust
Page 3 · response
Published 5 October 2022
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of a system to ensure that mechanical thromboprophylaxis instructions are carried out

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised2

Lack of clarity on VTE prophylaxis for patients who are both bariatric and neurosurgical

Failure to follow and understand the VTE policy for discharge risk reduction

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of venous thromboembolism risk assessment for hospital patients who are not admitted

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

NICE guidance not reflecting the use of LMWH with non-TED-stocking VTE prevention products

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised2

Absence of an active DVT policy

Failure to obtain and clarify discharging-hospital information about care needs and thromboprophylaxis

Concerns raised1

Lack of clarity about VTE risk-assessment responsibilities at hospital-to-community discharge

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to withhold low molecular weight heparin VTE prophylaxis in the presence of active bleeding

Concerns raised3

Failure to provide risk-appropriate thrombosis prophylaxis after elective knee replacement

Failure to ensure clinicians access accurate thrombosis prophylaxis guidance

Routine prescription of aspirin to high-risk patients regardless of prophylaxis guidance

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 3

Respondent positions 2

Actions described in response 1

Actions described in response 1

Actions described in response 2

Actions described in response 4

Respondent positions 2