PFD report

Audrey Margaret Lambert · Prevention of Future Deaths report

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Issued 5 Nov 2024•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised1

  1. Lack of national guidance for primary care clinicians on assessing whether to prolong anticoagulation for elderly immobile patients
    Part of recurring concern: Unreliable guidance for medication continuation and discontinuation decisions
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 recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Review guidance on stopping and starting VTE prophylaxis to determine whether an update is warranted.

    Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 5 November 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing national guidance addresses discharge VTE risk assessment and prophylaxis decisions, although it does not advise starting prophylaxis de novo in the community.

    Stated by National Institute for Health and Care ExcellenceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of national guidance for primary care clinicians on assessing whether to prolong anticoagulation for elderly immobile patients

Wider context from the report

“The inquest heard evidence that prior to the fall and fracture Mrs Lambert had been mobile. Following the operation her mobility was very limited. She was prescribed the standard heparin treatment post operatively. The inquest was told that it was recognised in her case that she had become very immobile since her fall. However the inquest was told that there was no national guidance that would assist clinicians in primary care in assessing whether they should consider prolonging the course of anti-coagulation prescribed in secondary care to reduce the ongoing risk of elderly immobile patients such as Mrs Lambert developing a fatal DVT in the community. ”

Is this part of a recurring concern?

Yes — Unreliable guidance for medication continuation and discontinuation decisions.

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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 guidance on stopping and starting VTE prophylaxis to determine whether an update is warranted.

Verbatim wording from the response

“I can confirm that we will review our guidance on stopping and starting VTE prophylaxis to see if an update is warranted. The potential scope of this work is to be confirmed but it may cover the management of people with immobility, if there is sufficient good quality evidence on which to base recommendations.”

Source location

Response from NICE
Page 2 · response
Published 5 November 2024

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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 national guidance addresses discharge VTE risk assessment and prophylaxis decisions, although it does not advise starting prophylaxis de novo in the community.

Verbatim wording from the response

“In the circumstances outlined in your report we believe that an assessment of the venous thromboembolism (VTE) risk, balanced against the prophylaxis risk, should have been made at discharge. Although our VTE guideline [NG89] does not give advice on starting VTE prophylaxis de novo in the community, it does give advice on starting and continuing pharmacological VTE prophylaxis after surgery (recommendation 1.11) and having a clear discharge plan. Decisions on prophylaxis should be driven by the needs of the individual, balancing the person’s individual risk of VTE against their risk of bleeding when deciding whether to offer pharmacological thromboprophylaxis to surgical and trauma patients (recommendation 1.1.6).”

Source location

Response from NICE
Page 1 · response
Published 5 November 2024

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026