PFD report

Adam Connolly Stuyvesant · Prevention of Future Deaths report

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Issued 6 Oct 2023•Wiltshire and Swindon

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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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

Select any concern, action or position to view the source wording.

Concerns raised2

  1. DVT risk assessment failing to account for immobilisation when determining anti-clotting medication prescribing
    Part of recurring concern: Unsafe medication prescribing
  2. Risk of deep vein thrombosis from lower-limb immobility associated with wearing a plastic boot
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.4

  1. Action

    Revise mobility information leaflets for patients wearing black boots.

    Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.
  2. Action

    Update the Trust policy to require VTE assessment for patients wearing a black boot with significant mobility reduction.

    Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.
  3. Action

    Relocate patient information leaflets and VTE assessment checklists to the black-boot storage area and remind Emergency Department staff to complete assessments for lower-limb casts or black boots.

    Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.

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

  1. Position

    The current VTE risk assessment is fit for purpose and aligns with the nationally recognised Plymouth Scoring system.

    Stated by Great Western Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

DVT risk assessment failing to account for immobilisation when determining anti-clotting medication prescribing

Wider context from the report

“(1) The wearing of a plastic boot can lead to lower limb immobility and the possibility of a restriction in the “calf pump function” which can lead to deep vein thrombosis. (2) The DVT risk assessment in use in the Emergency Department at The Great Western Hospital, made no provision to take account of the immobilisation when considering whether anti-clotting medication should be prescribed. (3) That without taking account of the immobility, as part of the DVT risk assessment, further patients may not be prescribed anti-clotting medication and as a result develop DVT, resulting in death from pulmonary embolus. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

Open source report

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

Risk of deep vein thrombosis from lower-limb immobility associated with wearing a plastic boot

Wider context from the report

“(1) The wearing of a plastic boot can lead to lower limb immobility and the possibility of a restriction in the “calf pump function” which can lead to deep vein thrombosis. (2) The DVT risk assessment in use in the Emergency Department at The Great Western Hospital, made no provision to take account of the immobilisation when considering whether anti-clotting medication should be prescribed. (3) That without taking account of the immobility, as part of the DVT risk assessment, further patients may not be prescribed anti-clotting medication and as a result develop DVT, resulting in death from pulmonary embolus. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Revise mobility information leaflets for patients wearing black boots.

Verbatim wording from the response

“Information leaflets regarding mobility of a patient wearing a black boot has been revised. We have communicated to all staff within the Emergency Department the requirement to ensure that both verbal and written patient information is provided and recorded as complete within the health care records.”

Source location

Response from Great Western Hospitals NHS Foundation Trust
Page 2 · response
Published 18 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update the Trust policy to require VTE assessment for patients wearing a black boot with significant mobility reduction.

Verbatim wording from the response

“The Trust has reviewed the assessment again following the regulation 28 and are confident that the current VTE risk assessment is fit for purpose. As part of the review our local VTE risk assessment was compared to the Plymouth Scoring system, a nationally recognised standard, to assess whether the appropriate treatment is being given to patients and we confirm it is in line with this standard. To guide staff, the Trust's policy was reviewed and updated to indicate that patients who receive a black boot to assist with mobility but have significant reductions in their mobility will require a VTE assessment.”

Source location

Response from Great Western Hospitals NHS Foundation Trust
Page 2 · response
Published 18 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Relocate patient information leaflets and VTE assessment checklists to the black-boot storage area and remind Emergency Department staff to complete assessments for lower-limb casts or black boots.

Verbatim wording from the response

“There has been an increased focus on the patient information leaflets and the VTE risk assessment checklist in the department for patients with a black boot and these have since been relocated to the area where the black boots are stored. This is to emphasise the importance of completing the correct documentation for VTE risk assessments for patient requiring a black boot. There has also been a MEMO reminder sent to all Emergency Department staff reminding them that they need to complete risk assessments for any patients who are wearing lower limb casts or black boot.”

Source location

Response from Great Western Hospitals NHS Foundation Trust
Page 2 · response
Published 18 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue spot-check audits of the changes, share results at Divisional Governance meetings, and take appropriate action where required.

Verbatim wording from the response

“We will continue to monitor the effectiveness of the changes by way of spot check audits within the department, these results will be shared at Divisional Governance meetings and appropriate actions taken as required.”

Source location

Response from Great Western Hospitals NHS Foundation Trust
Page 2 · response
Published 18 October 2023

Open published response

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 current VTE risk assessment is fit for purpose and aligns with the nationally recognised Plymouth Scoring system.

Verbatim wording from the response

“The Trust has reviewed the assessment again following the regulation 28 and are confident that the current VTE risk assessment is fit for purpose. As part of the review our local VTE risk assessment was compared to the Plymouth Scoring system, a nationally recognised standard, to assess whether the appropriate treatment is being given to patients and we confirm it is in line with this standard. To guide staff, the Trust's policy was reviewed and updated to indicate that patients who receive a black boot to assist with mobility but have significant reductions in their mobility will require a VTE assessment.”

Source location

Response from Great Western Hospitals NHS Foundation Trust
Page 2 · response
Published 18 October 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Communicate the requirement to provide and record verbal and written patient information within Emergency Department health records.

    Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.
  2. 2

    Include VTE education and training in local induction for all junior doctors commencing work in the Emergency Department.

    Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.

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 the requirement to provide and record verbal and written patient information within Emergency Department health records.

Verbatim wording from the response

“Information leaflets regarding mobility of a patient wearing a black boot has been revised. We have communicated to all staff within the Emergency Department the requirement to ensure that both verbal and written patient information is provided and recorded as complete within the health care records.”

Source location

Response from Great Western Hospitals NHS Foundation Trust
Page 2 · response
Published 18 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Include VTE education and training in local induction for all junior doctors commencing work in the Emergency Department.

Verbatim wording from the response

“VTE education and training is now a part of the local induction process for all junior doctors when they commence working in the emergency department.”

Source location

Response from Great Western Hospitals NHS Foundation Trust
Page 2 · response
Published 18 October 2023

Open published response
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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