PFD report

Tracey Elizabeth Rose · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 17 Oct 2023•East Riding and Hull

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
2

Of 1 recipient

Stated actions
2

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised2

  1. Failure to dispense prescribed dalteparin before discharge
    Part of recurring concern: Failure to ensure patients receive the correct prescribed medication at hospital dischargePart of recurring concern: Unreliable hospital discharge processes
  2. Failure to administer the final inpatient dose of dalteparin
    Part of recurring concern: Unsafe medication administration
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

Failure to dispense prescribed dalteparin before discharge

Wider context from the report

“(1) This woman was discharged home without her prescription of dalteparin being dispensed, also her last dose whilst in hospital may not have been given. Evidence was heard that missing up to three doses of this anticoagulant, in someone with increased risk factors for thromboembolic disease, may have significantly contributed to her developing a pulmonary embolism. ”

Is this part of a recurring concern?

Yes — Failure to ensure patients receive the correct prescribed medication at hospital discharge; Unreliable hospital discharge processes.

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

Failure to administer the final inpatient dose of dalteparin

Wider context from the report

“(1) This woman was discharged home without her prescription of dalteparin being dispensed, also her last dose whilst in hospital may not have been given. Evidence was heard that missing up to three doses of this anticoagulant, in someone with increased risk factors for thromboembolic disease, may have significantly contributed to her developing a pulmonary embolism. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

Open source report

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

    Require prescribers to enter an explanation when overriding serious electronic prescribing interaction alerts.

    Stated by Hull University Teaching Hospitals NHS Trust and Northern Lincolnshire and Goole NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2023.
  2. 2

    Bring prescription circumstances and investigation findings to the Trust VTE Steering Group to share learning.

    Stated by Hull University Teaching Hospitals NHS Trust and Northern Lincolnshire and Goole NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 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

Require prescribers to enter an explanation when overriding serious electronic prescribing interaction alerts.

Verbatim wording from the response

“Changes Implemented by the Trust since the death of Ms Rose In May 2023, changes were made to the adverse interaction alerts issued by the Trust’s electronic prescribing system. In circumstances where a serious potential adverse reaction is identified, the system now requires prescribing clinicians to type an explanation as to why they are overriding an alert, rather than simply ticking a box. This change is intended to make our clinicians pause and further consider the alert before deciding whether to override it.”

Source location

Response from Northern Lincolnshire and Goole NHS Foundation Trust
Page 3 · response
Published 30 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

Bring prescription circumstances and investigation findings to the Trust VTE Steering Group to share learning.

Verbatim wording from the response

“The circumstance regarding Ms Rose’s prescription and the findings of the investigations have also been brought to the Trust’s VTE Steering Group for learning to be shared.”

Source location

Response from Northern Lincolnshire and Goole NHS Foundation Trust
Page 3 · response
Published 30 October 2023

Open published response
Back to top

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