Concerns raised 7 Failure to provide TED stockings or similar thromboprophylactic equipment View source Failure to learn from and reflect on DVT-related care to change practice View source Absence of an active DVT policy View source Failure to obtain and clarify discharging-hospital information about care needs and thromboprophylaxis View source Lack of joined-up clinical leadership and coordination between management and clinical teams View source Failure to mobilise immobile residents to minimise DVT risk View source Failure to identify and minimise residents’ DVT risk View source See 4 more concerns
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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.
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. The report was sent to Frome Care Village; that does not assign responsibility.
PFD Monitor interpretation Failure to provide TED stockings or similar thromboprophylactic equipment
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Frome Care Village; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from and reflect on DVT-related care to change practice
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Frome Care Village; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Frome Care Village; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and clarify discharging-hospital information about care needs and thromboprophylaxis
Wider context from the report “I am concerned following the evidence presented to the Inquest that:
(i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet:
(a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan ;
(b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT;
(c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT
(ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk.
I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken.
Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Frome Care Village; that does not assign responsibility.
PFD Monitor interpretation Lack of joined-up clinical leadership and coordination between management and clinical teams
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Frome Care Village; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Frome Care Village; that does not assign responsibility.
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.
” Open source report
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Addressed to Frome Care Village (Alexis Care Limited), now represented here by Frome Care Village.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations