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
Distinct published reports
Individual concerns
16
A report can raise multiple concerns
Date range
2013–2024
First to latest report issue date
Stated actions
21
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
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
NHS trust7
Ministerial department4
Executive non-departmental public body2
Healthcare site2
Devolved government1
Health and care professional regulator1
Health and social care service regulator1
Integrated care board1
Local health board1
Multi-service care provider1
Residential care home1
Social care inspectorate1
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.
County Durham and Darlington
Concerns raised1
Failure to consider alternative treatment to reduce DVT/PE risk
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.
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
Action
Review and update the patient safety investigation report and action plan to cover the patient’s acute and community care.
Stated by County Durham and Darlington NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Cheshire
Concerns raised1
Failure of the DVT risk assessment tool to assess patients at risk despite no significantly reduced mobility
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Work with NHS England to consider the VTE risk assessment tool in light of the concerns raised.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 12 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Insufficient evidence prevents recommending one VTE risk assessment tool over another.
Stated by National Institute for Health and Care ExcellenceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Concerns about the VTE risk assessment tool should be directed to the Department of Health and Social Care.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Somerset
Concerns raised3
Absence of an active DVT policy
Failure to mobilise immobile residents to minimise DVT risk
Failure to identify and minimise residents’ DVT risk
This report raised 4 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.
Manchester South
Concerns raised1
Lack of clinician recognition of the potentially fatal DVT risk in immobilised surgical patients
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Maintain warnings in combined hormonal contraceptive product information about venous thromboembolism risks, surgery and immobilisation.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
Action
Review combined hormonal contraceptive venous thromboembolism risks and update product information with revised risk estimates and antithrombotic-treatment advice.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
Action
Introduce user cards and prescriber checklists covering clot risks, warning symptoms, and alerts about planned or recent surgery or immobilisation.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
Action
Communicate revised venous thromboembolism risk estimates and risk-reduction measures to prescribers through Drug Safety Update.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
Action
Request updates to the product information for the small number of combined hormonal contraceptive products missing information from the venous thromboembolism review.
Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
DVT risk factors and their link to oral contraception are not new or under-recognised issues.
Stated by Medicines and Healthcare products Regulatory AgencyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing product warnings, risk estimates, antithrombotic advice, user materials and prescriber tools provide risk-minimisation measures for combined hormonal contraceptives.
Stated by Medicines and Healthcare products Regulatory AgencyExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Clinical guidance addresses DVT prevention, diagnosis and management, including VTE risk assessment and antithrombotic prevention for surgery and trauma.
Stated by Medicines and Healthcare products Regulatory AgencyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North London
Concerns raised1
Lack of recommendations or guidance for prevention of DVT and pulmonary embolus in upper limb surgery
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Deliver education and awareness sessions on the VTE policy and publicise policy and guideline updates through orthopaedic governance and audit meetings.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Incorporate the approved VTE risk-assessment leaflet into the revised Orthopaedics Handbook.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Add a thromboprophylaxis domain to the local pre-operative checklist to prompt anaesthetists to record prophylaxis on the anaesthetic drug chart.
Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Action
Discuss the revised pre-operative checklist process with the Head of Anaesthetics.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Responsibility for addressing the lack of national DVT and pulmonary embolus prevention guidelines lies with the Department of Health.
Stated by Royal Free London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing local VTE guidance requires no amendment because it is consistent with national guidance and covers major elbow surgery.
Stated by Royal Free London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Shropshire, Telford and Wrekin
Concerns raised1
Failure to record a differential diagnosis of DVT
This report raised 11 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Audit ED staff compliance with documentation requirements and repeat the audit monthly.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust was unaware of the suspected clot, and a painful leg alone was not necessarily indicative of a clot.
Stated by the Shrewsbury and Telford Hospital NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure to examine injection sites and DVT sites
This report raised 3 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Review national guidance and local protocols for DVT management and examination of intravenous injection sites.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham Community Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
Action
Remind all healthcare staff to complete appropriate observations during physical examinations of injection and DVT sites.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham Community Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing local protocols for examining injection and DVT sites reflect national guidelines, so no new examination protocol is required.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham Community Healthcare NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
South Wales Central
Concerns raised1
Haphazard DVT management system
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.
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
Action
Implement a streamlined DVT pathway directing suspected cases to radiology, initiating primary treatment before ultrasound, and ensuring positive and negative results receive appropriate follow-up.
Stated by Hywel Dda University LHBStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Record all suspected DVT referrals and follow up 48 hours later to confirm receipt of results.
Stated by RHAYADER GROUP PRACTICEStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Refer patients through the Hereford Hospital or Bronglais Hospital DVT pathways.
Stated by RHAYADER GROUP PRACTICEStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
DVT management in primary care is accepted practice; hospital-only management was not considered necessary where appropriate safeguards are followed.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Coventry
Concerns raised1
Failure of the DVT investigation protocol to provide repeat proximal leg vein ultrasound scanning after a positive D-dimer test and negative proximal leg ultrasound scan
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Undertake routine extended whole-leg scans covering veins below the knee to the calf trifurcation.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Contact high-risk patients with raised D-dimers after 5–7 days and arrange repeat scanning when symptoms have not settled.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Routine repeat scans are unnecessary because whole-leg scans are routinely performed and follow-up scans are arranged when symptoms fail to settle.
Stated by University Hospitals Coventry and Warwickshire NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
South Yorkshire (Western)
Concerns raised1
Failure to consider full-leg scanning for suspected lower-leg DVT
This report raised 10 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 A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Evidence does not establish that lower-leg scanning would have changed treatment, because benefits of treating isolated distal DVT remain unclear.
Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
NICE is responsible for considering and responding on whether lower-leg scanning should be included in relevant clinical guidance.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The hospital will not change distal DVT ultrasound processes because additional scans may not detect all clots and empiric anticoagulation creates risks.
Stated by Barnsley Hospital NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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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.
