Vauna LEEMING · Prevention of Future Deaths report

On 3 April 2024 I commenced an investigation and opened an inquest into the death of Vauna LEEMING. The investigation concluded at the end of the inquest on 15 January 2025.

The conclusion of the inquest was that Mrs. Leeming “died from natural causes, to which a recent fractured neck of femur and surgical repair thereof contributed”.

In answer to the questions “when, where and how did Mrs. Leeming come by her death?”, I recorded as follows:

“On 6.2.24 Vauna Leeming was admitted to Worcestershire Royal Hospital after suffering an accidental fall at home, and was found to have sustained a fractured right neck of femur. She underwent surgery to repair the fracture on 8.2.24, from which she initially made a satisfactory recovery. However, on 23.3.24 her condition deteriorated, and she tested positive for Covid-19. She went on to suffer a pulmonary embolism and, despite treatment, declined and died in hospital on 25.3.24.”

1) Following Mrs. Leeming’s surgery on 8.2.24, measures were put in place to prevent the formation of a deep vein thrombosis and/or pulmonary embolism. Those measures were prescriptions for anticoagulation medication (Enoxaparin ) and for compression stockings. The inquest heard evidence that over the 46 days between her surgery and Mrs. Leeming’s death:
(a) on 2 days ( 10 and 13.2.24 ) no documentation was completed by nurses to show whether Enoxaparin had in fact been administered;
(b) on a total of 15 days (including 5 consecutive days in one week ) no documentation was completed by nurses to show whether compression stockings had been fitted and were being worn;
2) It was of particular concern that for 5 consecutive days, no nurse had noticed or raised with a senior colleague that the prescription charts had not been completed to show that compression stockings had been fitted. This suggests either that there is little understanding of a nurse’s professional duty to report such omissions, or that the practice of not checking and completing such important documentation is commonplace;
3) The inquest heard evidence that whilst in its induction to new nurse employees, the Trust emphasises the importance of completing documentation, it is still heavily reliant on agency nurses, for whom it cannot be expected to provide such an induction;
4) I am concerned that the evidence in this case highlights that there is still insufficient awareness among employed and agency nurses at the Trust’s hospitals of their professional duty:
(a) to complete important documentation such as prescription charts; and
(b) to report any omissions in the completion of such documentation to a senior colleague.