Concerns raised 1
Failure to consider alternative treatment to reduce DVT/PE risk View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Janet Rice · 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 Rice, aged 65, died in hospital from pulmonary and cerebral embolism after surgery for a hip fracture sustained in an accidental fall. Anti-coagulant medication was inconsistently administered, including during a period when she was experiencing acute delirium; concerns included the absence of a capacity assessment, best-interests decision, escalation, or consideration of alternative treatment. The report also raised concerns about delays and limitations in the Trust’s patient safety investigation and the limited scope of related training.
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 consider alternative treatment to reduce DVT/PE risk
Wider context from the report “(2) The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti coagulant and does not consider or address the omission to administer anti coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE .
” Source location Janet Rice · 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 Review and update the patient safety investigation report and action plan to cover the patient’s acute and community care.
Verbatim wording from the response “The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti-coagulant and does not consider or address the omission to administer anti-coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti-coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti-coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE.” Source location Response from Durham and Darlington NHS
Open published response
23 Apr 2024 Nuliyati BUSINJE · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1
Failure of the DVT risk assessment tool to assess patients at risk despite no significantly reduced mobility View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Nuliyati BUSINJE · 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
Nuliyati Businje was an inpatient on a psychiatric unit when, after abnormal observations and worsening hyperglycaemia during her admission, she suffered a cardiac arrest. Post-mortem examination found a massive pulmonary embolus due to deep venous thrombosis. The concerns included limitations in VTE risk assessment for patients with risk factors other than reduced mobility, insufficient recognition of increased DVT risk among psychiatric inpatients, and inadequate awareness of how clot-related observations may normalise.
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 the DVT risk assessment tool to assess patients at risk despite no significantly reduced mobility
Wider context from the report “1. Despite evidence to suggest that mobility is not the ultimate deciding factor of risk of DVT, the risk assessment tool as currently drafted and relied upon by clinicians would suggest that there is no further need for assessment . This raises a risk of future deaths for those patients such as Ms Businje who were at risk of VTE, or those with cancer for example, but who do not have significantly reduced mobility and would therefore fall outside of the risk assessment .
” Source location Nuliyati BUSINJE · 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 Work with NHS England to consider the VTE risk assessment tool in light of the concerns raised.
Verbatim wording from the response “It is recognised that inpatients on psychiatric wards may be at higher risk of venous thromboembolism due to reduced mobility, poor fluid intake, restraint, catatonia, sedation and antipsychotic use. NICE’s guidance on Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism (NG89) makes clear that all acute psychiatric patients should be assessed to identify VTE and bleeding risk on admission, using a risk assessment tool. The Department will work with NHS England to consider the VTE risk assessment tool, in light of the concerns you have raised.” Source location Response from DHSC
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 Insufficient evidence prevents recommending one VTE risk assessment tool over another.
Verbatim wording from the response “With regard to the assessment of VTE risk in people with psychiatric disorders admitted to hospital, in the NICE guideline on venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism we recommend that clinicians should use ‘a tool published by a national UK body, professional network or peer-reviewed journal’ to assess VTE risk, however we do not recommend a particular risk assessment tool as there is not enough evidence to support the use of one over another and during development of the guideline, the committee made a research recommendation in this area, reflecting the uncertainty in the evidence for one risk tool over another.” Source location Response from 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 Concerns about the VTE risk assessment tool should be directed to the Department of Health and Social Care.
Verbatim wording from the response “Concerns regarding the risk assessment tool referenced in NG89 would need to be directed to the Department of Health and Social Care.” Source location Response from NICE
Open published response
7 Nov 2023 Irene Joy White · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 3
Absence of an active DVT policy View source Failure to mobilise immobile residents to minimise DVT risk View source Failure to identify and minimise residents’ DVT risk View source
This report raised 4 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
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.
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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 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
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 mobilise immobile residents to minimise DVT risk
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
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 identify and minimise residents’ DVT risk
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
Open source report
15 May 2023 Rebekah Juliet Mills · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of clinician recognition of the potentially fatal DVT risk in immobilised surgical patients View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Medicines and Healthcare products Regulatory Agency
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
Medicines and Healthcare products Regulatory Agency
Maintain warnings in combined hormonal contraceptive product information about venous thromboembolism risks, surgery and immobilisation.
View source
Medicines and Healthcare products Regulatory Agency
Review combined hormonal contraceptive venous thromboembolism risks and update product information with revised risk estimates and antithrombotic-treatment advice.
View source
Medicines and Healthcare products Regulatory Agency
Introduce user cards and prescriber checklists covering clot risks, warning symptoms, and alerts about planned or recent surgery or immobilisation.
View source
Medicines and Healthcare products Regulatory Agency
Communicate revised venous thromboembolism risk estimates and risk-reduction measures to prescribers through Drug Safety Update.
View source
Medicines and Healthcare products Regulatory Agency
Request updates to the product information for the small number of combined hormonal contraceptive products missing information from the venous thromboembolism review.
View source See 2 more actions
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AI-generated summary
Rebekah Juliet Mills · 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
Rebekah Juliet Mills suffered a knee injury in an accidental skiing fall, underwent surgery, collapsed at home several days later, and died from a pulmonary embolism. The inquest identified unclear clinical guidance about reducing the risk of DVT in young, immobile patients taking oral contraception who require surgery, with differing approaches and insufficient recognition of the potential fatal risk.
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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 clinician recognition of the potentially fatal DVT risk in immobilised surgical patients
Wider context from the report “During the course of the inquest evidence was given that the guidance for clinicians in relation to reducing the risk of DVT when dealing with patients such as Ms Mills who are young and on oral contraception but are immobile following an accident and require surgery is unclear. That lack of clarity can give rise to a differing approach and a lack of recognition of the potential fatal risk that patients such as Ms Mills can face in such a situation .
The evidence was that greater clarity and greater understanding of the risks could prevent future deaths.
” Source location Rebekah Juliet Mills · 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 Maintain warnings in combined hormonal contraceptive product information about venous thromboembolism risks, surgery and immobilisation.
Verbatim wording from the response “All oral hormonal contraceptives licensed in the UK have included warnings in the SmPC since the early 2000s on the risks of venous thromboembolism (VTE) which includes deep vein thrombosis (DVT) and pulmonary embolism. These warnings highlight the need to stop treatment at least 4 weeks prior to and for 2 weeks after elective operations and during immobilisation. The risks of VTE with combined hormonal contraceptives were further reviewed in 2013 by MHRA in conjunction with other regulators in the EU. The review confirmed the known relative risks of VTE for different groups of combined hormonal contraceptives (newer contraceptives compared to so-called second generation combined hormonal contraceptives containing levonorgestrel, norethisterone or norgestimate) but found some changes in the magnitude of the risks of VTE in all women (with and without hormonal contraceptive use).” Source location Response from Medicines & Healthcare products Regulatory Agency
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 combined hormonal contraceptive venous thromboembolism risks and update product information with revised risk estimates and antithrombotic-treatment advice.
Verbatim wording from the response “All oral hormonal contraceptives licensed in the UK have included warnings in the SmPC since the early 2000s on the risks of venous thromboembolism (VTE) which includes deep vein thrombosis (DVT) and pulmonary embolism. These warnings highlight the need to stop treatment at least 4 weeks prior to and for 2 weeks after elective operations and during immobilisation. The risks of VTE with combined hormonal contraceptives were further reviewed in 2013 by MHRA in conjunction with other regulators in the EU. The review confirmed the known relative risks of VTE for different groups of combined hormonal contraceptives (newer contraceptives compared to so-called second generation combined hormonal contraceptives containing levonorgestrel, norethisterone or norgestimate) but found some changes in the magnitude of the risks of VTE in all women (with and without hormonal contraceptive use).” Source location Response from Medicines & Healthcare products Regulatory Agency
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 user cards and prescriber checklists covering clot risks, warning symptoms, and alerts about planned or recent surgery or immobilisation.
Verbatim wording from the response “The review also appreciated that it may not always be possible to suspend use of a contraceptive in advance of prolonged immobilisation, major surgery, surgery to the legs or pelvis, neurosurgery, or major trauma. Consequently, the changes to the product information incorporated clear advice that antithrombotic treatment should be considered if the contraceptive has not been discontinued in these circumstances. Additionally, a user card and a prescriber checklist were also introduced for contraceptive users and prescribers respectively on the risks of blood clots, when these are increased, and symptoms to watch out for. These documents included a reminder to alert healthcare professionals including surgeons if surgery or immobilisation is planned or has recently occurred.” Source location Response from Medicines & Healthcare products Regulatory Agency
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 Communicate revised venous thromboembolism risk estimates and risk-reduction measures to prescribers through Drug Safety Update.
Verbatim wording from the response “We communicated the revised estimates of risk and on the new measures to reduce the risks to prescribers in 2014 through our newsletter Drug Safety Update¹.” Source location Response from Medicines & Healthcare products Regulatory Agency
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 Request updates to the product information for the small number of combined hormonal contraceptive products missing information from the venous thromboembolism review.
Verbatim wording from the response “In response to your request, we have reviewed the product information for all combined hormonal contraceptives and identified that the information for a small number of combined hormonal contraceptive products was not updated to include the new information as expected following the VTE review. We will request these be addressed as soon as possible. We would note however that the information currently provided for these products is less complete than the updated information described above rather than contradictory to it.” Source location Response from Medicines & Healthcare products Regulatory Agency
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 DVT risk factors and their link to oral contraception are not new or under-recognised issues.
Verbatim wording from the response “Also, as highlighted in the response provided to you from NHS England, the risk factors for DVT and the link to oral contraception are not new or under-recognised issues. The prevention, diagnosis and management of DVT fall under the remit of clinical guidance. Risk factors, diagnosis and management of VTE are clearly set out in the NICE Pulmonary Embolism Clinical Knowledge Summary². Guidance on risk assessment for VTE and on the use of antithrombotic preventative measures for patients undergoing surgery or who have experienced a trauma are addressed in NICE guideline (NG89)³: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. We welcome however the additional briefing that the Greater Manchester Integrated Care board have requested to focus on the learnings for clinicians from Rebekah’s death.” Source location Response from Medicines & Healthcare products Regulatory Agency
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 Existing product warnings, risk estimates, antithrombotic advice, user materials and prescriber tools provide risk-minimisation measures for combined hormonal contraceptives.
Verbatim wording from the response “All oral hormonal contraceptives licensed in the UK have included warnings in the SmPC since the early 2000s on the risks of venous thromboembolism (VTE) which includes deep vein thrombosis (DVT) and pulmonary embolism. These warnings highlight the need to stop treatment at least 4 weeks prior to and for 2 weeks after elective operations and during immobilisation. The risks of VTE with combined hormonal contraceptives were further reviewed in 2013 by MHRA in conjunction with other regulators in the EU. The review confirmed the known relative risks of VTE for different groups of combined hormonal contraceptives (newer contraceptives compared to so-called second generation combined hormonal contraceptives containing levonorgestrel, norethisterone or norgestimate) but found some changes in the magnitude of the risks of VTE in all women (with and without hormonal contraceptive use).” Source location Response from Medicines & Healthcare products Regulatory Agency
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 Clinical guidance addresses DVT prevention, diagnosis and management, including VTE risk assessment and antithrombotic prevention for surgery and trauma.
Verbatim wording from the response “Also, as highlighted in the response provided to you from NHS England, the risk factors for DVT and the link to oral contraception are not new or under-recognised issues. The prevention, diagnosis and management of DVT fall under the remit of clinical guidance. Risk factors, diagnosis and management of VTE are clearly set out in the NICE Pulmonary Embolism Clinical Knowledge Summary². Guidance on risk assessment for VTE and on the use of antithrombotic preventative measures for patients undergoing surgery or who have experienced a trauma are addressed in NICE guideline (NG89)³: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. We welcome however the additional briefing that the Greater Manchester Integrated Care board have requested to focus on the learnings for clinicians from Rebekah’s death.” Source location Response from Medicines & Healthcare products Regulatory Agency
Open published response
6 Aug 2019 Joseph Arthur Charles · Prevention of Future Deaths report North London
View report summary
Concerns raised 1
Lack of recommendations or guidance for prevention of DVT and pulmonary embolus in upper limb surgery View source
Linked response
Royal Free London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Royal Free London NHS Foundation Trust
Deliver education and awareness sessions on the VTE policy and publicise policy and guideline updates through orthopaedic governance and audit meetings.
View source
Royal Free London NHS Foundation Trust
Incorporate the approved VTE risk-assessment leaflet into the revised Orthopaedics Handbook.
View source
Royal Free London NHS Foundation Trust
Add a thromboprophylaxis domain to the local pre-operative checklist to prompt anaesthetists to record prophylaxis on the anaesthetic drug chart.
View source
Royal Free London NHS Foundation Trust
Discuss the revised pre-operative checklist process with the Head of Anaesthetics.
View source See 1 more action
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AI-generated summary
Joseph Arthur Charles · 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
Joseph Arthur Charles fell at home, underwent right elbow surgery, was discharged, and was later found unresponsive in bed by his wife. The concern was that national guidance existed for preventing deep vein thrombosis and pulmonary embolus after lower-limb surgery but not after upper-limb surgery.
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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 recommendations or guidance for prevention of DVT and pulmonary embolus in upper limb surgery
Wider context from the report “That although there are clear National guidelines for the prevention of DVT and pulmonary embolus there are no such recommendations or guidance for upper limb surgery .
” Source location Joseph Arthur Charles · 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 Deliver education and awareness sessions on the VTE policy and publicise policy and guideline updates through orthopaedic governance and audit meetings.
Verbatim wording from the response “Review of the Trust’s Venous Thromboembolism (VTE) prevention policy
It was agreed there is no need to amend or change the present guidance, which is consistent with national guidelines for lower limb surgery and specifically mentions any major surgery over 90 minutes, which would include the elbow replacement surgery which Mr. Charles had. However, there is now an opportunity to strengthen education, training and awareness of this policy is amongst the surgical team. ████████ Consultant Haematologist, is to conduct an education and awareness event at the next Orthopaedic Governance Meeting on Tuesday 1 October 2019, and in addition there will be an audit meeting to publicise the policy and guidelines updates on Tuesday 3 December 2019.” Source location 2019-0277-Response-by-North-Middlesex-Hospital
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 Incorporate the approved VTE risk-assessment leaflet into the revised Orthopaedics Handbook.
Verbatim wording from the response “Publishing a VTE risk assessment template/flyer in Orthopaedics
Discussions are currently being held by the hospital’s Thrombosis Group regarding the publishing of a new leaflet, which is due for Trust-wide implementation by 31 January 2020. Following approval this leaflet will be incorporated into the Orthopaedics Handbook, which is due to be revised by 28 February 2020.” Source location 2019-0277-Response-by-North-Middlesex-Hospital
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 Add a thromboprophylaxis domain to the local pre-operative checklist to prompt anaesthetists to record prophylaxis on the anaesthetic drug chart.
Verbatim wording from the response “Review of the VTE risk assessment in theatres
Although appropriate risk assessments are undertaken prior to routine surgery, our investigation revealed that the required medication(VTE prophylaxis) in this case had not always been prescribed. As such, an extra domain has been added to our local pre-operative checklist to ensure that the anaesthetists will write up thromboprophylaxis on the anaesthetic drug chart during surgery. This change in process will be discussed with the Head of Anaesthetics by 31 October 2019.” Source location 2019-0277-Response-by-North-Middlesex-Hospital
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 Discuss the revised pre-operative checklist process with the Head of Anaesthetics.
Verbatim wording from the response “Review of the VTE risk assessment in theatres
Although appropriate risk assessments are undertaken prior to routine surgery, our investigation revealed that the required medication(VTE prophylaxis) in this case had not always been prescribed. As such, an extra domain has been added to our local pre-operative checklist to ensure that the anaesthetists will write up thromboprophylaxis on the anaesthetic drug chart during surgery. This change in process will be discussed with the Head of Anaesthetics by 31 October 2019.” Source location 2019-0277-Response-by-North-Middlesex-Hospital
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 Responsibility for addressing the lack of national DVT and pulmonary embolus prevention guidelines lies with the Department of Health.
Verbatim wording from the response “We write following receipt of the Regulation 28 report issued following the conclusion of the inquest into the death of the above named. Whilst we understand that the lack of national guidelines for the prevention of DVT and pulmonary embolus following upper limb surgery is a matter for the Department of Health to address, the Trust decided to undertake a review of our local policy and procedures.” Source location 2019-0277-Response-by-North-Middlesex-Hospital
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 Existing local VTE guidance requires no amendment because it is consistent with national guidance and covers major elbow surgery.
Verbatim wording from the response “Review of the Trust’s Venous Thromboembolism (VTE) prevention policy
It was agreed there is no need to amend or change the present guidance, which is consistent with national guidelines for lower limb surgery and specifically mentions any major surgery over 90 minutes, which would include the elbow replacement surgery which Mr. Charles had. However, there is now an opportunity to strengthen education, training and awareness of this policy is amongst the surgical team. ████████ Consultant Haematologist, is to conduct an education and awareness event at the next Orthopaedic Governance Meeting on Tuesday 1 October 2019, and in addition there will be an audit meeting to publicise the policy and guidelines updates on Tuesday 3 December 2019.” Source location 2019-0277-Response-by-North-Middlesex-Hospital
Open published response
Concerns raised 1
Failure to record a differential diagnosis of DVT View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Mark Richard HINTON · 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
Mark Richard HINTON attended A&E with right calf pain and swelling after being advised to attend because of a possible clot. He was discharged before a markedly raised D-Dimer result became available; the inquest recorded pulmonary embolus due to deep vein thrombosis and bleeding duodenal ulcer, with a conclusion of “Preventable Natural Cause”. Concerns included failures in recording and communicating the D-Dimer request and result, delayed testing, inadequate documentation, and other system and process failures.
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 record a differential diagnosis of DVT
Wider context from the report “(3) Other matters arising.
a) A second set of observations should have been made before Mark was discharged. This did not happen.
b) The D-Dimer test result was delayed due to a systems error with the CS2500 machine. It is stated that this may have happened intermittently and is then corrected. Had the system error not occurred it is likely that the (8th) result would have been available on screen for the discharging doctor to review.
c) Telephone results are not made if the patient is an in-patient in A&E. The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category?
d) Differential diagnosis. Had all the information to the discharging doctor a differential diagnosis of DVT may have been made and recorded .
e) A body map had not been completed at any time.
f) Oramorph was recorded as having been given but not checked. Also it may the mask symptoms of pain.
g) Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.
h) The absence of documentation made it difficult if not impossible to resolve factual discrepancies between members of staff.
i) The impression given by witnesses was that they were under pressure (racing against the clock) to meet the 4 hour deadline in A&E.
” Source location Mark Richard HINTON · Prevention of Future Deaths 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 Audit ED staff compliance with documentation requirements and repeat the audit monthly.
Verbatim wording from the response “Agreed. The Trust relies on the integrity of individuals to maintain professional standards of completing documentation. There are clear guidelines issued by both the NMC and the GMC which should be adhered to. An action from the RCA was to audit whether the ED staff were compliant in completing documentation. The initial audit results showed poor compliance and the plan is for the audit to be repeated monthly. The results have been discussed by the senior ED management team who are tasked with bringing improvement.” Source location 2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
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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 The Trust was unaware of the suspected clot, and a painful leg alone was not necessarily indicative of a clot.
Verbatim wording from the response “g. Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.” Source location 2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
Open published response
21 Jan 2019 Neil Antony Black · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to examine injection sites and DVT sites View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Neil Antony Black · 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
Neil Antony Black was remanded into HMP Birmingham on 8 March 2018 after disclosing extensive alcohol and intravenous drug use and a DVT in his right leg. He became increasingly unwell in prison, was admitted to hospital on 12 March with suspected sepsis, and was diagnosed with infective endocarditis and lung abscesses before deteriorating to multi-organ failure and dying on 31 March 2018. The report identified concerns about inconsistent physical observations, inadequate interaction between prison healthcare teams, unclear responsibilities, and the lack of examination of his leg and injection sites.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to examine injection sites and DVT sites
Wider context from the report “3. Neil Black came into prison with a DVT in his right leg which was caused by IV drug use injecting into his groins. His groins sites and leg were not examined during his time at the prison . Consideration needs to be given to ensure there is a clear protocol for the examination of injection sites and DVT sites.
” Source location Neil Antony Black · 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 Review national guidance and local protocols for DVT management and examination of intravenous injection sites.
Verbatim wording from the response “We have carefully reviewed the national guidelines and our current protocols in relation to both the management of deep vein thrombosis (DVT) and the physical examination of intravenous (IV) injection sites. We are content that our local protocols reflect national guidelines. Unfortunately in this particular case our local protocols were not followed and a reminder went out to all healthcare staff on 13 February 2019 to ensure that all appropriate observations at any physical examination are carried out.” Source location 2019-0024-Response-by-Birmingham-Community-Healthcare-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 Remind all healthcare staff to complete appropriate observations during physical examinations of injection and DVT sites.
Verbatim wording from the response “We have carefully reviewed the national guidelines and our current protocols in relation to both the management of deep vein thrombosis (DVT) and the physical examination of intravenous (IV) injection sites. We are content that our local protocols reflect national guidelines. Unfortunately in this particular case our local protocols were not followed and a reminder went out to all healthcare staff on 13 February 2019 to ensure that all appropriate observations at any physical examination are carried out.” Source location 2019-0024-Response-by-Birmingham-Community-Healthcare-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 Existing local protocols for examining injection and DVT sites reflect national guidelines, so no new examination protocol is required.
Verbatim wording from the response “We have carefully reviewed the national guidelines and our current protocols in relation to both the management of deep vein thrombosis (DVT) and the physical examination of intravenous (IV) injection sites. We are content that our local protocols reflect national guidelines. Unfortunately in this particular case our local protocols were not followed and a reminder went out to all healthcare staff on 13 February 2019 to ensure that all appropriate observations at any physical examination are carried out.” Source location 2019-0024-Response-by-Birmingham-Community-Healthcare-NHS-Trust
Open published response
27 Jul 2017 Percy Jacks · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1
Haphazard DVT management system View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Percy Jacks · 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
Percy Jacks died from a pulmonary embolus after being found unresponsive the morning following treatment for chest pain. The report identified failings in the management of his anticoagulation medication, including poor communication between the hospital, GP surgery and care home, and inadequate systems for ensuring the medication continued for the intended period.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Haphazard DVT management system
Wider context from the report “(3) The evidence revealed a view from one of the hospital doctors to the effect that DVT management should be undertaken within the hospital setting rather than by the GP’s to ensure that a comprehensive and failsafe system operated rather than the somewhat haphazard one revealed by the evidence .
” Source location Percy Jacks · 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 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.
Verbatim wording from the response “The process of managing potential DVT patients has been streamlined and a definite pathway introduced. All GP referrals which suspected DVTs are referred direct to the Hospital's Radiology Department as per the attached protocol. It is incumbent on the GPs to commence their primary prior to an ultrasound scan being undertaken. Following their scan, if the result is positive, the patient is referred back to the A & E Department where they are reviewed by the on-call Physicians. There is a pre-printed letter that is completed by the on-call physicians to the GP with recommendations and this is also copied to the Anticoagulation Clinic. If the result of the scan is negative, the patient is referred back to their GP for further evaluation.” Source location 2017-0329-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 Record all suspected DVT referrals and follow up 48 hours later to confirm receipt of results.
Verbatim wording from the response “We have discussed this in our practice meeting and have made the following changes.” Source location 2017-0329-Response-by-Rhayader-Group-Practic
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 Refer patients through the Hereford Hospital or Bronglais Hospital DVT pathways.
Verbatim wording from the response “We have discussed this in our practice meeting and have made the following changes.” Source location 2017-0329-Response-by-Rhayader-Group-Practic
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 DVT management in primary care is accepted practice; hospital-only management was not considered necessary where appropriate safeguards are followed.
Verbatim wording from the response “3. The evidence revealed a view from one of the hospital doctors to the effect that DVT management should be undertaken within the hospital setting rather than by the GPs to ensure that a comprehensive and failsafe system operated rather than the somewhat haphazard one revealed by the evidence.” Source location 2017-0329-Response-by-Care-Quality-Commission
Open published response
25 Jul 2017 Mr Robert Dymond · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 1
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 View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mr Robert Dymond · 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
Mr Robert Dymond underwent elective left knee replacement surgery on 9 March 2017 and suffered a massive thromboembolic event the following morning, dying on 11 March 2017. Concerns included the management and follow-up of suspected deep vein thrombosis, the apparent failure to communicate the November 2016 DVT investigations and treatment to the surgical and anaesthetic teams, and their omission from the second pre-operative assessment.
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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 DVT investigation protocol to provide repeat proximal leg vein ultrasound scanning after a positive D-dimer test and negative proximal leg ultrasound scan
Wider context from the report “(1) Following referral to the UHCW DVT Clinic by his GP on 22 November 2016 with a suspected DVT, Mr Dymond, having a Wells score of 2, was assessed as being ‘likely’ to be suffering from a DVT – the investigations included a D-Dimer blood result of 0.97 – and he was discharged home with instructions to self-administer therapeutic LMWH (Clexane) doses at home twice daily in his stomach pending an ultrasound scan booked for 25 November 2016. The scan performed on 25 November 2016 apparently revealed no evidence of a DVT and he was discharged back to the care of his GP. Although the clinical management appeared to conform with the UHCW protocol in place at the time, this protocol did not appear to conform with NICE Guideline 144 (specifically section 1.1.3) which (since 2012) advises a repeat proximal leg vein ultrasound scan 6-8 days later for all patients with a positive D-dimer test and a negative proximal leg ultrasound scan ;
” Source location Mr Robert Dymond · Prevention of Future Deaths 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 Undertake routine extended whole-leg scans covering veins below the knee to the calf trifurcation.
Verbatim wording from the response “The reason that this practice is not adopted by the Trust is because at UHCW, we undertake a more extended scan as a routine which shows the leg veins below the knee to the trifurcation in the calf. This is discussed in NICE guideline 144 section 4.1 which states that whole leg scans do not routinely need a repeat scan. Therefore we believe that the Trust’s pathway goes beyond the minimum requirements and accordingly we exclude very low numbers of venous thromboembolism following discharge from the DVT service.” Source location 2017-0333-Response-by-University-Hospitals-Coventry-and-Warwickshire-NHS-Trust
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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 Contact high-risk patients with raised D-dimers after 5–7 days and arrange repeat scanning when symptoms have not settled.
Verbatim wording from the response “Further, the Trust’s standard practice in patients with a high risk Wells score and raised D-Dimers is to contact the patient 5-7 days later and arrange a repeat scan if the symptoms are not settling. Only a small proportion of patients who present with isolated distal DVTs extend to the proximal veins. Those that do not extend, rarely lead to clinically significant emboli as recognised by the British Society of Haematology national guidelines, a copy of which is attached by way of information.” Source location 2017-0333-Response-by-University-Hospitals-Coventry-and-Warwickshire-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 Routine repeat scans are unnecessary because whole-leg scans are routinely performed and follow-up scans are arranged when symptoms fail to settle.
Verbatim wording from the response “The reason that this practice is not adopted by the Trust is because at UHCW, we undertake a more extended scan as a routine which shows the leg veins below the knee to the trifurcation in the calf. This is discussed in NICE guideline 144 section 4.1 which states that whole leg scans do not routinely need a repeat scan. Therefore we believe that the Trust’s pathway goes beyond the minimum requirements and accordingly we exclude very low numbers of venous thromboembolism following discharge from the DVT service.” Source location 2017-0333-Response-by-University-Hospitals-Coventry-and-Warwickshire-NHS-Trust
Open published response
Concerns raised 1
Failure to consider full-leg scanning for suspected lower-leg DVT View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Barnsley Hospital NHS Foundation Trust Department of Health and Social Care
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AI-generated summary
Captain James Michael Bedford · 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
Captain James Michael Bedford, a senior long-haul airline pilot, developed a left-leg deep vein thrombosis and later collapsed after a flight from China. He suffered a pulmonary embolus and cerebral events, followed by an acute cerebral haemorrhage after treatment with heparin, and died on 30 June 2015. Concerns included differing hospital practices regarding lower-leg scanning for DVT and whether a full-leg scan at his first attendance might have provided an opportunity for treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider full-leg scanning for suspected lower-leg DVT
Wider context from the report “1. The inquest heard that the scanning practice followed after the first attendance was in accordance with NICE guidelines (indeed possibly a little in excess of the guidance) which did not include scanning of the lower leg . This was said to be on the basis that not all lower leg DVTs will be visible. Yet it became apparent that that there is mixed practice on this point, some hospitals clearly consider that lower leg scanning is worthwhile .
Hindsight strongly suggested that Captain Bedforth was developing clots in the left lower leg at the time of the first visit. The inquest found that a full leg scan might have provided the hospital with an opportunity to treat Captain Bedforth although it was accepted that no-one could be certain of this.
” Source location Captain James Michael Bedford · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evidence does not establish that lower-leg scanning would have changed treatment, because benefits of treating isolated distal DVT remain unclear.
Verbatim wording from the response “However, RSMVF also points out that the evidence for treating distal DVT alone is weak and cites a recent CACTUS trial (lancet haematology 2016) which showed no benefit in treating symptomatic below knee DVT. RSMVF is of the opinion that even if Captain Bedforth had had a full leg scan, and had been found to have a below knee DVT in April 2015, the evidence is not clear on whether he should have been immediately anticoagulated at that time.” Source location 2016-0368-Response-by-Department-of-Health
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 NICE is responsible for considering and responding on whether lower-leg scanning should be included in relevant clinical guidance.
Verbatim wording from the response “The inquest heard that the scanning practice followed after Captain Bedforth’s first attendance in April 2015, was in accordance with NICE guidelines which do not include scanning the lower leg. As it became apparent there is mixed clinical practice on this point, your view is that some hospitals consider that lower leg scanning is worthwhile. As most hospitals are, or should be, working to NICE guidelines, I therefore advised that you should consider inviting NICE to respond to this case directly. My officials provided you with contact details and I understand that NICE are looking into this and will respond directly to you and copy me into their reply. I have also consulted the Royal Society of Medicine Venous Forum (RSMVF) and asked for their comments on this case.” Source location 2016-0368-Response-by-Department-of-Health
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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 The hospital will not change distal DVT ultrasound processes because additional scans may not detect all clots and empiric anticoagulation creates risks.
Verbatim wording from the response “1. The current NICE guidance for Venous Thromboembolism advises proximal leg USS investigation for those patients who are high risk based on Wells scoring and those who are low risk with a positive D-dimer. If negative, the patient should undergo a second proximal leg USS in 6-8 days time to exclude proximal propagation of a clot from a distal DVT. The rationale behind the NICE guidance is evidence-based following multiple studies.” Source location 2016-0368-Barnsley-Hospital-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.