Recurring concern

Unreliable DVT diagnosis and management

Get email alerts

Request correction

First reported 23 Oct 2013•Latest report 23 Jul 2024

Definition

What this concern includes

Includes failures in the dedicated DVT process, including recognition and diagnostic assessment, risk tools and guidance, reassessment after changing circumstances or follow-up visits, referral and scanning decisions, thromboprophylaxis decisions, treatment and coordination of care.

Not included

Excludes pulmonary-embolism management when DVT is not the material concern.
Excludes generic clinical assessment, documentation, referral or medication failures unless they directly impair the DVT diagnosis or management process.
Excludes failures occurring after DVT has been reliably diagnosed and managed when the remaining deficiency is unrelated downstream care.
Excludes generic venous-thromboembolism concerns without a material DVT component, except where the assertion directly concerns the shared DVT process.

Reports: 13
Individual concerns: 16
Date range: 2013–2024
Stated actions: 21

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 Care4

National Institute for Health and Care Excellence2

Barnsley Hospital NHS Foundation Trust1

Beckenham Beacon Urgent Care Centre1

Birmingham and Solihull Mental Health NHS Foundation Trust1

Birmingham Community Healthcare NHS Foundation Trust1

Bromley Healthcare Community Interest Company1

Care Inspectorate Wales1

Care Quality Commission1

Cator Medical Centre1

County Durham and Darlington NHS Foundation Trust1

Frome Care Village1

General Medical Council1

Hywel Dda University LHB1

NHS England1

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.

25 Nov2014
Portsmouth and South East Hampshire
Concerns raised1
1. Failure to re-assess relevant fracture clinic out-patients under the DVT assessment policy
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
  Reassess venous thromboembolism risk factors at every fracture-clinic return for patients with lower-limb injuries.
  Stated by Portsmouth Hospitals University NHS TrustStated planned
2. Action
  Update the plaster-room “in trouble” form to document venous thromboembolism assessment recommendations.
  Stated by Portsmouth Hospitals University NHS TrustStated in progress
AI-generated summary

Stephen Anthony Mayoll · 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

Stephen Anthony Mayoll fell from a ladder at work and sustained a right Achilles tendon injury, for which he received outpatient treatment at Queen Alexandra Hospital between 11 and 20 June 2013. He became very unwell at home on 21 June and died in hospital at 03.20 hours on 22 June 2013 from a pulmonary thromboembolism arising from a deep vein thrombosis. Concerns included the lack of reassessment under the hospital’s DVT assessment policy for similar fracture-clinic outpatients and delays in making fracture-clinic doctors’ notes available.

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 re-assess relevant fracture clinic out-patients under the DVT assessment policy
Wider context from the report
“1- Out-patients with similar injuries to Mr Mayoll's returning to the fracture clinic at Queen Alexandra Hospital experiencing problems with their treatment or for periodic review are not subject to re-assessment under the hospital's DVT assessment policy. If they were, there would be less risk of their developing DVT's during the course of their treatment. ”
Source location
Stephen Anthony Mayoll · Prevention of Future Deaths report
Page 1 · 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
Reassess venous thromboembolism risk factors at every fracture-clinic return for patients with lower-limb injuries.

Verbatim wording from the response
“1. Patients who return to the fracture clinic with lower limb injuries as “in trouble” or for routine review, will have a reassessment of their risk factors for VTE each time they attended, the result of which will be considered by the doctor reviewing them. This will be documented via the normal route on a plaster room “in trouble” form which is currently being updated and will include the recommendations from the Inquiry relating to VTE assessment.”

Source location
2014-0515-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 1 · response
Published 25 November 2014
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
Update the plaster-room “in trouble” form to document venous thromboembolism assessment recommendations.

Verbatim wording from the response
“1. Patients who return to the fracture clinic with lower limb injuries as “in trouble” or for routine review, will have a reassessment of their risk factors for VTE each time they attended, the result of which will be considered by the doctor reviewing them. This will be documented via the normal route on a plaster room “in trouble” form which is currently being updated and will include the recommendations from the Inquiry relating to VTE assessment.”

Source location
2014-0515-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 1 · response
Published 25 November 2014
Open published response
29 Apr2014
West Sussex
Concerns raised2
1. Failure to apply DVT avoidance policy to patients in psychiatric units
2. Failure to apply DVT prophylaxis policy and clerking to patients entering psychiatric units
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

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 avoidance policy to patients in psychiatric units
Wider context from the report
“(3) By way of emphasis and duplication, that if anything, the NICE recommendations and policy for DVT avoidance is as relevant to patients being treated in psychiatric units as in any other units providing patient care. ”
Source location
Janet BLACKMAN · 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 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
Page 2 · concerns
Open source report
23 Oct2013
Inner South London
Concerns raised1
1. Failure of registration, assessment and referral documentation and consultation records to facilitate early diagnosis of DVT and low-threshold referral to A&E
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

Jacqueline Allwood · 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

Jacqueline Allwood attended a GP with several days of calf pain and concern about a family history of thrombosis. She was not referred to hospital to exclude DVT and later died from pulmonary thromboembolism secondary to DVT. Concerns included whether registration, assessment and referral processes supported early diagnosis and referral, and whether the consulting GP understood and followed appropriate standards for history-taking and examination.

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 of registration, assessment and referral documentation and consultation records to facilitate early diagnosis of DVT and low-threshold referral to A&E
Wider context from the report
“(1) The registration, assessment and referral forms and consultation records of and between the Urgent Care Centre and Cator Medical Practice may not facilitate the early diagnosis of DVT and the need for a low threshold of referral to A&E. ”
Source location
Jacqueline Allwood · Prevention of Future Deaths report
Page 7 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to re-assess relevant fracture clinic out-patients under the DVT assessment policy

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 raised2

Failure to apply DVT avoidance policy to patients in psychiatric units

Failure to apply DVT prophylaxis policy and clerking to patients entering psychiatric units

Concerns raised1

Failure of registration, assessment and referral documentation and consultation records to facilitate early diagnosis of DVT and low-threshold referral to A&E

Actions described in response 2