Concerns raised 1
Failure of the obstetric VTE prophylaxis and management policy to comply with NICE guidance View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Euphemia Lumsden Aldred · 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
Euphemia Aldred fell at home, sustained fractures to her left leg and ankle, and was treated in hospital with a plaster cast. After discharge, she was no longer prescribed low molecular weight heparin, developed a deep vein thrombosis and pulmonary embolism, and died; the report identified that the relevant Trust policy did not comply with NICE guidance on venous thrombo-embolism prevention.
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× 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 of the obstetric VTE prophylaxis and management policy to comply with NICE guidance
Wider context from the report “The East Lancashire Hospitals Trust Policy Document: Venous Thrombo-Embolism (VTE) (on Obstetric) Part 1 Prophylaxis, Part II Management of VTE V1.4 October 2015 did not comply with the NICE Guidance on Venous Thrombo-embolism in Adults: Reducing the Risk in Hospital: CG92 January 2010 .
” Source location Euphemia Lumsden Aldred · Prevention of Future Deaths report
Open source report
Concerns raised 2
Failure to provide consistent prophylaxis for patients with lower limb immobilisation View source Lack of a venous thromboembolism risk assessment tool for patients discharged with lower limb immobilisation View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Sharon Louise Henshall · 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
Sharon Louise Henshall sustained a fractured ankle while skiing in Italy and died in the early hours of 18 February 2015 after collapsing from a pulmonary embolus. The report raised concerns that there was no venous thromboembolism risk-assessment tool or interim process for patients discharged with lower-limb immobilisation, and that access to prophylaxis varied between hospitals.
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× 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 consistent prophylaxis for patients with lower limb immobilisation
Wider context from the report “The evidence of both ████████ Consultant in Emergency Medicine, and ████████ Consultant Physician, was that there is currently no venothromboembolism risk assessment model in place in the Emergency Department to assess the risk of VTE in patients discharged with lower limb immobilisation. The reason for this appeared to be that the evidence base regarding risk factors and success of prophylaxis is poor.
████████ accepted that Sharon Louise Henshall should have been assessed. His evidence was that he and colleagues were working on developing a tool that would try to extrapolate data from the inpatient assessment tools to create an outpatient tool, but that it was difficult to know what benefit would be derived from giving prophylactic treatment.
Dr McDowell's evidence was that creating a risk assessment tool would be a very easy thing to do, but that it would require a "major change in pathways," which would need to involve primary care to monitor complications.
(1) To have no assessment in place at all and to offer nothing in an area of known risks on the basis that the evidence base is varied, as opposed to having a tool in place, even one that recognises only the highest and obviously known/understood risk factors, seems unlikely to be adequate, and gives rise to a concern that future deaths will occur;
(2) To have no interim tool in place pending the outcome of a 'major change in pathways' seems unlikely to be adequate;
(3) Dr McDowell's evidence was that other European countries routinely give LMWH to patients with lower limb immobilisation, yet this is not something that is done at LTHtr, or uniformly across Trusts in England and Wales ;
(4) According to ████████ the NICE guidance in this area, which was updated in June 2015, states that clinicians should have a discussion about risks and benefits with each individual, which necessarily requires having some form of tool or model in place to facilitate that discussion, yet there is no such tool in place within LTHtr;
(5) The evidence of both ████████████████████ was that whether patients will be offered prophylaxis varies according to which hospital patients attend, since some Trusts offer it and some Trusts do not , and different Trusts have differing risk assessment tools taking different risk factors into account. It is of concern that due to the absence of national guidance there appears to be something of a 'postcode lottery' with regards to prophylaxis being offered or not .
” Source location Sharon Louise Henshall · Prevention of Future Deaths report
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 Lack of a venous thromboembolism risk assessment tool for patients discharged with lower limb immobilisation
Wider context from the report “The evidence of both ████████ Consultant in Emergency Medicine, and ████████ Consultant Physician, was that there is currently no venothromboembolism risk assessment model in place in the Emergency Department to assess the risk of VTE in patients discharged with lower limb immobilisation . The reason for this appeared to be that the evidence base regarding risk factors and success of prophylaxis is poor.
████████ accepted that Sharon Louise Henshall should have been assessed. His evidence was that he and colleagues were working on developing a tool that would try to extrapolate data from the inpatient assessment tools to create an outpatient tool, but that it was difficult to know what benefit would be derived from giving prophylactic treatment.
Dr McDowell's evidence was that creating a risk assessment tool would be a very easy thing to do, but that it would require a "major change in pathways," which would need to involve primary care to monitor complications.
(1) To have no assessment in place at all and to offer nothing in an area of known risks on the basis that the evidence base is varied, as opposed to having a tool in place, even one that recognises only the highest and obviously known/understood risk factors, seems unlikely to be adequate, and gives rise to a concern that future deaths will occur;
(2) To have no interim tool in place pending the outcome of a 'major change in pathways' seems unlikely to be adequate ;
(3) Dr McDowell's evidence was that other European countries routinely give LMWH to patients with lower limb immobilisation, yet this is not something that is done at LTHtr, or uniformly across Trusts in England and Wales;
(4) According to ████████ the NICE guidance in this area, which was updated in June 2015, states that clinicians should have a discussion about risks and benefits with each individual, which necessarily requires having some form of tool or model in place to facilitate that discussion, yet there is no such tool in place within LTHtr ;
(5) The evidence of both ████████████████████ was that whether patients will be offered prophylaxis varies according to which hospital patients attend, since some Trusts offer it and some Trusts do not, and different Trusts have differing risk assessment tools taking different risk factors into account. It is of concern that due to the absence of national guidance there appears to be something of a 'postcode lottery' with regards to prophylaxis being offered or not.
” Source location Sharon Louise Henshall · Prevention of Future Deaths report
Open source report
10 Aug 2015 LORRAINE JOYCE BIRD · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1
Failure to implement thromboprophylaxis guidance for patients requiring temporary limb immobilisation View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Colchester Hospital University NHS Foundation Trust East and North Hertfordshire Teaching NHS Trust NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Colchester Hospital University NHS Foundation Trust
Reaffirm approval to commence the thromboprophylaxis pathway for emergency patients with acute lower-limb trauma.
View source
Colchester Hospital University NHS Foundation Trust
Seek Medicines Management Committee agreement, including resolution of funding arrangements, for the thromboprophylaxis guidance.
View source
Colchester Hospital University NHS Foundation Trust
Continue the education programme for emergency department staff on the thromboprophylaxis guidance.
View source
Colchester Hospital University NHS Foundation Trust
Introduce the thromboprophylaxis guidance and pathway for emergency department patients with acute lower-limb trauma once funding is agreed.
View source
East and North Hertfordshire Teaching NHS Trust
Review current VTE guidance against NICE and Royal College of Emergency Medicine recommendations.
View source See 2 more actions
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AI-generated summary
LORRAINE JOYCE BIRD · 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
Lorraine Joyce Bird fractured her ankle after a fall and later attended a plaster room with numbness in her foot. The report identifies concerns that a developing deep vein thrombosis was not recognised or medically reviewed, that there was no adequate assessment protocol, and that she had not received low molecular weight heparin. The inquest concluded that this resulted in a lost opportunity for further treatment and that she died on 13 September 2014.
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× 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 implement thromboprophylaxis guidance for patients requiring temporary limb immobilisation
Wider context from the report “(1) In September 2013 The College of Emergency Medicine issued a “Guideline for the use of Thromboprophylaxis in Ambulatory Patients Requiring Temporary Limb Immobilisation”. This recommends the use of Low Molecular Weight Heparin (LMWH) to be used until the plaster is removed.
(2) When Lorraine Bird attended Colchester Hospital she was not given LMWH. The hospital had not yet introduced the Guideline , although they were in the process of trying to agree the funding to enable them to adopt it.
” Source location LORRAINE JOYCE BIRD · Prevention of Future Deaths report
Open source report
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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 Reaffirm approval to commence the thromboprophylaxis pathway for emergency patients with acute lower-limb trauma.
Verbatim wording from the response “The Trust has undertaken as a matter of urgency, the implementation of the Emergency Medicine Network (GEMNet) pathway relating to Thromboprophylaxis for Emergency Department patients with acute lower limb trauma. Approval for commencement was reaffirmed by the Thrombosis Management board on 7 September this year and agreement is being sought from the North East Essex Medicines Management committee at the end of September 2015. An education programme for ED staff has commenced and it is planned to introduce the guidance as soon as funding is agreed.” Source location 2015-0315-Response-by-Colchester-Hospital-University-NHS-Trust
Open published response
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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 Seek Medicines Management Committee agreement, including resolution of funding arrangements, for the thromboprophylaxis guidance.
Verbatim wording from the response “The Trust has undertaken as a matter of urgency, the implementation of the Emergency Medicine Network (GEMNet) pathway relating to Thromboprophylaxis for Emergency Department patients with acute lower limb trauma. Approval for commencement was reaffirmed by the Thrombosis Management board on 7 September this year and agreement is being sought from the North East Essex Medicines Management committee at the end of September 2015. An education programme for ED staff has commenced and it is planned to introduce the guidance as soon as funding is agreed.” Source location 2015-0315-Response-by-Colchester-Hospital-University-NHS-Trust
Open published response
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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 Continue the education programme for emergency department staff on the thromboprophylaxis guidance.
Verbatim wording from the response “The Trust has undertaken as a matter of urgency, the implementation of the Emergency Medicine Network (GEMNet) pathway relating to Thromboprophylaxis for Emergency Department patients with acute lower limb trauma. Approval for commencement was reaffirmed by the Thrombosis Management board on 7 September this year and agreement is being sought from the North East Essex Medicines Management committee at the end of September 2015. An education programme for ED staff has commenced and it is planned to introduce the guidance as soon as funding is agreed.” Source location 2015-0315-Response-by-Colchester-Hospital-University-NHS-Trust
Open published response
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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 Introduce the thromboprophylaxis guidance and pathway for emergency department patients with acute lower-limb trauma once funding is agreed.
Verbatim wording from the response “The Trust has undertaken as a matter of urgency, the implementation of the Emergency Medicine Network (GEMNet) pathway relating to Thromboprophylaxis for Emergency Department patients with acute lower limb trauma. Approval for commencement was reaffirmed by the Thrombosis Management board on 7 September this year and agreement is being sought from the North East Essex Medicines Management committee at the end of September 2015. An education programme for ED staff has commenced and it is planned to introduce the guidance as soon as funding is agreed.” Source location 2015-0315-Response-by-Colchester-Hospital-University-NHS-Trust
Open published response
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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 current VTE guidance against NICE and Royal College of Emergency Medicine recommendations.
Verbatim wording from the response “Prior to this incident there was no written guidance available to the Plaster room technicians. Current venous thromboembolic (VTE) guidance (incorporating NICE and Royal College of Emergency Medicine recommendations) is under review with full compliance with all recommendation currently anticipated for March 2016. Pending approval and ratification of this new overarching policy, the Clinical Director for Orthopaedics has issued immediate interim guidance to all plaster room technicians and fracture clinic medical staff.” Source location 2015-0315-Response-by-East-North-Hertfordshire-NHS-Trust
Open published response
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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 Implementation of the new pathway is delayed because funding is not assured.
Verbatim wording from the response “• An Education programme for the Emergency Department has been introduced to support the implementation of the guidance. The new pathway across primary and secondary care will commence on the 2 November 2015 as funding is not assured for implementation.” Source location 2015-0315-Response-by-NHS-England
Open published response
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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 Pathway implementation was delayed by unresolved community funding, patient-passport printing, prolonged sick leave, and severe staffing constraints.
Verbatim wording from the response “In response to this a lead consultant was identified and along with colleagues drew up a pathway that would enable local implementation of this guidance. All the relevant parties both within the hospital and community services were involved with development of the pathway. Implementation was delayed due to initial lack of clarity regarding funding of LMWH and blood tests in the community and secondly a delay in printing of a patient passport which had been planned to be supported by an external company that included both information and a pathway of care.” Source location 2015-0315-Response-by-Colchester-Hospital-University-NHS-Trust
Open published response
Concerns raised 1
Lack of guidance for thromboprophylaxis management in patients with restricted mobility who are not in casts View source
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AI-generated summary
David Andrew Bladen · 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 Andrew Bladen ruptured his right quadriceps tendon after falling down stairs and underwent reconstructive surgery. He received thromboprophylaxis during and shortly after surgery but no extended treatment after discharge, and died on 2 September 2014 from a massive pulmonary embolism. The principal concern was the absence of clear guidance on optimum thromboprophylaxis for patients with restricted mobility due to a brace rather than a cast.
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× 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 guidance for thromboprophylaxis management in patients with restricted mobility who are not in casts
Wider context from the report “(1) Absence of guidance for optimum thromboprophylaxis management in patients who are not in casts but still have restriction of mobility eg. due to a brace.
” Source location David Andrew Bladen · Prevention of Future Deaths report
Open source report
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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 Update the clinical guideline and prepare a new scope through the routine surveillance process.
Verbatim wording from the response “As part of our routine surveillance process, this guideline is to be updated and a new scope will be prepared as part of the process. We have not yet scheduled this project into our work programme, however I will make arrangements for a copy of your report to be forwarded to guideline developers at the appropriate time so that they are aware of the circumstances around this case and your concerns about the lack of specific guidance for patients in a brace. Please let me know if you or Mr Bladen’s family would prefer that this information should not be shared.” Source location 2015-0079-Response-by-NICE
Open published response
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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 Forward the report to guideline developers so they can consider the concerns about guidance for patients in braces.
Verbatim wording from the response “As part of our routine surveillance process, this guideline is to be updated and a new scope will be prepared as part of the process. We have not yet scheduled this project into our work programme, however I will make arrangements for a copy of your report to be forwarded to guideline developers at the appropriate time so that they are aware of the circumstances around this case and your concerns about the lack of specific guidance for patients in a brace. Please let me know if you or Mr Bladen’s family would prefer that this information should not be shared.” Source location 2015-0079-Response-by-NICE
Open published response
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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 Available evidence does not warrant a specific prophylaxis recommendation for patients in braces.
Verbatim wording from the response “As you are aware we make a specific recommendation on pharmacological VTE prophylaxis to patients with lower limb casts, however there was no evidence to indicate that a specific recommendation on prophylaxis for patients in a brace was warranted.” Source location 2015-0079-Response-by-NICE
Open published response
4 Aug 2014 Carol Lynne Walker · Prevention of Future Deaths report West Yorkshire (Eastern)
View report summary
Concerns raised 1
Failure to routinely administer chemical thromboprophylaxis to conservatively treated lower-limb injury patients in immobilising casts considered at low risk of venous thromboembolism View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Carol Lynne Walker · 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
Carol Lynne Walker died at home on 19 November 2013 after developing a pulmonary thromboembolism due to deep vein thrombosis following a left ankle fracture treated with a plastercast. The report raised concerns that chemical thromboprophylaxis and formal venous thromboembolism risk assessments were not routinely provided for conservatively treated lower-limb injuries immobilised in casts that were considered low 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 Failure to routinely administer chemical thromboprophylaxis to conservatively treated lower-limb injury patients in immobilising casts considered at low risk of venous thromboembolism
Wider context from the report “1. I understand that at the time it was not standard practice in either the Orthopaedic Department or the Emergency Department at Harrogate District Hospital to routinely administer Chemical Thrombo Prophylaxis to patients with conservatively treated lower limb injuries immobilising cast considered to be at low risk of venous thromboembolism .
2. Nor was it standard practice in the Trust for a formal venous thromboembolism risk assessment to be undertaken in this patient group.
” Source location Carol Lynne Walker · Prevention of Future Deaths report
Open source report
29 Apr 2014 Janet BLACKMAN · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Failure to apply DVT prophylaxis policy and clerking to patients entering psychiatric units View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Janet BLACKMAN · 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
Janet Blackman became unwell and was treated for hyperthyroidism and low sodium before being transferred between a medical unit and a psychiatric unit. She died after developing a pulmonary embolus due to deep calf venous thrombosis; the report noted that the psychiatric unit could not administer the prescribed heparin prophylaxis and raised concerns about continuity of physical healthcare and application of DVT prevention policy in psychiatric settings.
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 apply DVT prophylaxis policy and clerking to patients entering psychiatric units
Wider context from the report “(2) It would seem that the logic of the DVT prophylactic policy as recommended by NICE is not applied to those patients coming into the psychiatric units – or if it were then Mrs Blackman would have been subject to the same clerking process on each of her admissions to the HKU and thereafter would have been able to receive the prophylaxis care that had been prescribed for her in the AMU.
” Source location Janet BLACKMAN · Prevention of Future Deaths report
Open source report
13 Feb 2013 Francoise Simone Annabel SNAPE · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1
Lack of knowledge and consideration of NICE guidance on mechanical anti-DVT devices View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Francoise Simone Annabel SNAPE · 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
Mrs Snape was admitted to Worcestershire Royal Hospital on 2 August 2014 after an infarcted stroke and later developed a massive pulmonary embolus. Thromboembolic medication caused a catastrophic bleed resulting in her death. Concerns included the absence of a VTE assessment and failure to consider relevant NICE guidance on mechanical anti-DVT devices, which represented a lost opportunity for informed care and may have changed the outcome.
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 knowledge and consideration of NICE guidance on mechanical anti-DVT devices
Wider context from the report “(1) No VTE assessment was ever made of Mrs Snape. The explanation given by ████████ was that staff were too busy to complete the form and that because she had had a stroke heparin could not be given and therefore the paperwork was unnecessary.
(2) NICE guidelines regarding the use of mechanical anti DVT devices instead of heparin in high risk cases was not considered . ████████ indicated in his evidence that the guidance on such matters was to be found in "general" guidance regarding DVTs and not in "stroke" guidance. The clear difference was that he was not aware of the content of the general guidance despite it being specifically referred to as involving stroke patients .
It was clear in the Inquest that the absence of a formally completed VTE assessment and lack of knowledge of NICE guidelines amounted to a lost opportunity to make informed decisions for the care of Mrs Snape which may (but only may) have changed the outcome for her.
(3)
” Source location Francoise Simone Annabel SNAPE · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.