PFD report

Ellen Mercer · Prevention of Future Deaths report

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Issued 26 Apr 2024•Berkshire

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
2

Raised in this report

Recipients
3

Named on the report

Responses found
5

Of 3 recipients

Stated actions
14

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. Failure of policy to clearly define a 24-hour VTE risk assessment period that accounts for emergency department waits
  2. Failure of current policies to require VTE risk assessment for emergency department patients during prolonged waits
    Part of recurring concern: Failure to provide safe ongoing care during prolonged emergency-department stays
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.8

  1. Action

    Ask NICE to update VTE guidance so assessments occur within 14 hours of a decision to admit.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  2. Action

    Work with the Electronic Patient Record team to add an EPIC prompt when the 12-hour Emergency Department threshold is reached.

    Stated by Frimley Park HospitalStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  3. Action

    Revise the VTE Policy to require assessment after more than 12 hours in the Emergency Department and clarify prophylaxis timescales, exclusions and responsible specialties.

    Stated by Frimley Park HospitalStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    NICE, rather than NHS England, is responsible for changing national VTE guidance on when assessments should occur.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 of policy to clearly define a 24-hour VTE risk assessment period that accounts for emergency department waits

Wider context from the report

“1. Patients are unfortunately waiting increasingly longer times in emergency departments – not just in waiting areas, but also after being seen by clinical staff and waiting for admission to a ward or discharge from the hospital. During this time, current policies do not require VTE risk assessment. 2. The policy for this trust suggests that the 24 hour period (during which VTE risk assessment must take place) starts only when a patient is “admitted” to hospital, i.e. when a decision is taken to admit them to a ward – which could be many hours after they have originally attended the emergency department. 3. The policy as currently drafted implies that VTE risk assessment is essentially not relevant for emergency department patients. 4. If current policies require VTE risk assessment to take place within 24 hours, the point at which that 24 hour period starts is not sufficiently clear and does not take long waits in emergency departments into account. I am concerned that policies may need to reflect the current reality on the ground. 5. I suspect that this issue may be a national one. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 of current policies to require VTE risk assessment for emergency department patients during prolonged waits

Wider context from the report

“1. Patients are unfortunately waiting increasingly longer times in emergency departments – not just in waiting areas, but also after being seen by clinical staff and waiting for admission to a ward or discharge from the hospital. During this time, current policies do not require VTE risk assessment. 2. The policy for this trust suggests that the 24 hour period (during which VTE risk assessment must take place) starts only when a patient is “admitted” to hospital, i.e. when a decision is taken to admit them to a ward – which could be many hours after they have originally attended the emergency department. 3. The policy as currently drafted implies that VTE risk assessment is essentially not relevant for emergency department patients. 4. If current policies require VTE risk assessment to take place within 24 hours, the point at which that 24 hour period starts is not sufficiently clear and does not take long waits in emergency departments into account. I am concerned that policies may need to reflect the current reality on the ground. 5. I suspect that this issue may be a national one. ”

Is this part of a recurring concern?

Yes — Failure to provide safe ongoing care during prolonged emergency-department stays.

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

Ask NICE to update VTE guidance so assessments occur within 14 hours of a decision to admit.

Verbatim wording from the response

“However, to further clarify this issue and acknowledging that there is an ongoing heightened demand in EDs leading to significant waits, NHS England’s national Patient Safety Team have been in touch with NICE to suggest that their guidance is updated to reflect that VTE assessments should be undertaken within 14 hours of a ‘decision to admit’, as opposed to admission. NICE have advised that they will be addressing the issue with their Prioritisation Board.”

Source location

Response from NHS England
Page 2 · response
Published 9 May 2024

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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

Work with the Electronic Patient Record team to add an EPIC prompt when the 12-hour Emergency Department threshold is reached.

Verbatim wording from the response

“• Work with the Electronic Patient Record team to make changes to the Trust’s electronic record keeping system, EPIC, so that a prompt is generated at the relevant time; and”

Source location

Response from Firmley Health NHS Foundation Trust
Page 4 · response
Published 9 May 2024

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

Revise the VTE Policy to require assessment after more than 12 hours in the Emergency Department and clarify prophylaxis timescales, exclusions and responsible specialties.

Verbatim wording from the response

“At the meeting the clinicians agreed in principle that patients attending the ED who have been present (for whatever reason) for 12 hours or more should be subject to a VTE risk assessment. It was acknowledged that the finer detail of the Trust’s revised policy would need careful consideration and all were particularly mindful of the impact of adding to workloads of ED staff in the absence of additional resource.”

Source location

Response from Firmley Health NHS Foundation Trust
Page 3 · response
Published 9 May 2024

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

Establish a working group to amend the policy and plan rollout, with fortnightly meetings and progress reporting to VTE committees.

Verbatim wording from the response

“In order to progress the above steps, the Trust has assembled a working group who will have responsibility for the amendments to the policy and the plan for rollout. The intention is for the group to meet fortnightly and for a representative to feedback to the afore mentioned VTE committees as to the group’s progress.”

Source location

Response from Firmley Health NHS Foundation Trust
Page 4 · response
Published 9 May 2024

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 Data Quality Improvement Plan to assess effectiveness and inform further steps to embed revised VTE practice.

Verbatim wording from the response

“In due course the Trust will also need to update the Data Quality Improvement Plan in order to assess the effectiveness of the changes and inform consideration as to whether any further steps are needed to ensure the revised practice is embedded successfully across the Trust. The committees that will oversee progress will primarily be the VTE committee who meet every other month and also report into Patient Safety Steering Group (PSSG) quarterly. Care Governance Committee and quality assurance committees have oversight of the VTE committee’s work and PSSG’s reviews of VTE performance.”

Source location

Response from Firmley Health NHS Foundation Trust
Page 4 · response
Published 9 May 2024

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

Issue guidance clarifying that admitting specialty teams are responsible for VTE risk assessments once they assume clinical responsibility in the emergency department.

Verbatim wording from the response

“We note from your Regulation 28: Report to Prevent Future Deaths notice that you identify the delay in a risk assessment for the prevention (as opposed to treatment) of venous thromboembolism (VTE) being a concern and that the timing of the risk assessment may be subject to variation. As a medical royal college we have issued guidance on clinical responsibility for patients who are located in the emergency department but who have been seen by and are under the clinical care of a team other than the emergency medicine team. This guidance states “Once a patient in the ED is seen by a specialty team, then that patient becomes the responsibility of the specialty team” [3]. This guidance was issued to ensure that emergency department doctors are able to prioritise the assessment and treatment of newly arrived patients in a timely fashion.”

Source location

Response from Royal College of Emergency Medicine
Page 1 · response
Published 9 May 2024

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

Produce a Safety Alert for Physicians addressing delayed admission and prophylactic treatment risks.

Verbatim wording from the response

“In light of this case we will produce a Safety Alert for Physicians, and also liaise with NHSE England National Clinical Director for Urgent and Emergency Care, National Clinical Director for Patient Safety and The Society for Acute Medicine.”

Source location

Response from Royal College of Physicians
Page 2 · response
Published 9 May 2024

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

Ask the prioritisation board to consider whether guidance should be developed on VTE risk assessment for emergency department patients before admission.

Verbatim wording from the response

“The scope of the guideline does not cover people in the emergency department prior to admission. We have therefore not made any recommendations that cover the circumstances described in your report.”

Source location

Response from National Institute for Health and Care Excellence
Page 1 · response
Published 9 May 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

NICE, rather than NHS England, is responsible for changing national VTE guidance on when assessments should occur.

Verbatim wording from the response

“The National Institute for Health and Care Excellence (NICE), who I note you have also addressed your Report to, are responsible for the relevant clinical guidelines [NG89] for VTE risk assessment.”

Source location

Response from NHS England
Page 1 · response
Published 9 May 2024

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

VTE risk assessment remains the admitting specialty team’s responsibility, including when patients remain in the emergency department.

Verbatim wording from the response

“We do not think it is likely to be effective to require ED staff, who are already experiencing issues with their capacity, to undertake a specific risk assessment for VTE. This is supported by the Royal College of Emergency Medicine (RCEM), who we note in their response to you, have stated that ‘it is not the role of emergency medicine doctors to be undertaking risk assessments that specifically relate to the hospital admission process’ and that this is the ‘role of the admitting specialty doctors, even when a patient is still in the ED’. The RCEM has issued clinical guidance on the clinical responsibility for patients who are located in the ED but who have been seen and are under the clinical care of another team. The guidance states that ‘Once a patient in the ED is seen by a specialty team, then the patient becomes the responsibility of the speciality team’.”

Source location

Response from NHS England
Page 2 · response
Published 9 May 2024

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

Emergency medicine doctors are not responsible for VTE risk assessments specifically relating to the hospital admission process.

Verbatim wording from the response

“It is not the role of emergency medicine doctors to be undertaking risk assessments that specifically relate to the hospital admission process; this is the role of the admitting specialty doctors, even when the patient is still in the ED. We would however expect emergency department doctors to undertake a VTE risk assessment for those patients who are being admitted for a prolonged period under the care of the ED team to a clinical area such as a Clinical Decision Unit or Observation Ward run solely by the emergency department.”

Source location

Response from Royal College of Emergency Medicine
Page 1 · response
Published 9 May 2024

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

Admitting specialty doctors are responsible for VTE risk assessments relating to hospital admission, including while patients remain in the emergency department.

Verbatim wording from the response

“It is not the role of emergency medicine doctors to be undertaking risk assessments that specifically relate to the hospital admission process; this is the role of the admitting specialty doctors, even when the patient is still in the ED. We would however expect emergency department doctors to undertake a VTE risk assessment for those patients who are being admitted for a prolonged period under the care of the ED team to a clinical area such as a Clinical Decision Unit or Observation Ward run solely by the emergency department.”

Source location

Response from Royal College of Emergency Medicine
Page 1 · response
Published 9 May 2024

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

Each hospital is responsible for establishing a local policy defining clinical responsibility for patients awaiting admission in emergency departments.

Verbatim wording from the response

“In the current context of delays for admission we do not believe that timing interventions from admission is appropriate, and these should be modified as timings from attendance or speciality referral. Each hospital should have a local policy that agrees on clinical responsibility for patients waiting for admission in Emergency Departments.”

Source location

Response from Royal College of Physicians
Page 1 · response
Published 9 May 2024

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

Timing venous thromboembolism interventions from admission is inappropriate amid admission delays; timings should instead run from attendance or specialty referral.

Verbatim wording from the response

“In the current context of delays for admission we do not believe that timing interventions from admission is appropriate, and these should be modified as timings from attendance or speciality referral. Each hospital should have a local policy that agrees on clinical responsibility for patients waiting for admission in Emergency Departments.”

Source location

Response from Royal College of Physicians
Page 1 · response
Published 9 May 2024

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 guideline does not cover people in emergency departments before admission, so it makes no recommendations for that circumstance.

Verbatim wording from the response

“The scope of the guideline does not cover people in the emergency department prior to admission. We have therefore not made any recommendations that cover the circumstances described in your report.”

Source location

Response from National Institute for Health and Care Excellence
Page 1 · response
Published 9 May 2024

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.6

  1. 1

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  2. 2

    Publish and update the urgent and emergency care recovery delivery plan addressing capacity, workforce, discharge, out-of-hospital care and access.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  3. 3

    Restart VTE risk-assessment data collection and update guidance requiring inpatient assessment within 14 hours of admission.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  4. 4

    Circulate Trust-wide communication explaining the revised policy, EPIC prompt and safety rationale.

    Stated by Frimley Park HospitalStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  5. 5

    Liaise with national urgent and emergency care, patient safety, and acute medicine leaders about delayed admission responsibilities and treatment timing.

    Stated by Royal College of PhysiciansStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  6. 6

    Implement an organisation-wide approach to prioritising and selecting guidance topics, overseen by a single prioritisation board.

    Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.

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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 9 May 2024

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

Publish and update the urgent and emergency care recovery delivery plan addressing capacity, workforce, discharge, out-of-hospital care and access.

Verbatim wording from the response

“NHS England recognises the pressures that continue to be placed on Urgent & Emergency Care (UEC) services. In January 2023, we published the Delivery Plan for recovering urgent and emergency care services which set out our plans and ambitions to improve the service over the next two years. The plan commits to improvements in five key areas:”

Source location

Response from NHS England
Page 1 · response
Published 9 May 2024

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

Restart VTE risk-assessment data collection and update guidance requiring inpatient assessment within 14 hours of admission.

Verbatim wording from the response

“Following a period of consultation, the VTE risk assessment data collection restarted as of 1st April 2024. NHS England’s VTE Risk Assessment Guidance has been updated with the following: “To support the collection of data, NHS England has clarified that risk assessment should be completed on inpatients within 14hrs of admission; NICE guidelines state that where required, pharmacological thromboprophylaxis should be started within 14hrs of admission, therefore risk assessment should be completed prior to this, unless otherwise stated in the population-specific recommendations.””

Source location

Response from NHS England
Page 2 · response
Published 9 May 2024

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

Circulate Trust-wide communication explaining the revised policy, EPIC prompt and safety rationale.

Verbatim wording from the response

“• Trust wide communication to be circulated by email explaining the changes to the policy, the Epic prompt and the rationale for the same.”

Source location

Response from Firmley Health NHS Foundation Trust
Page 4 · response
Published 9 May 2024

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

Liaise with national urgent and emergency care, patient safety, and acute medicine leaders about delayed admission responsibilities and treatment timing.

Verbatim wording from the response

“In light of this case we will produce a Safety Alert for Physicians, and also liaise with NHSE England National Clinical Director for Urgent and Emergency Care, National Clinical Director for Patient Safety and The Society for Acute Medicine.”

Source location

Response from Royal College of Physicians
Page 2 · response
Published 9 May 2024

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

Implement an organisation-wide approach to prioritising and selecting guidance topics, overseen by a single prioritisation board.

Verbatim wording from the response

“We have recently implemented an organisation-wide approach to prioritisation and topic selection. This is overseen by a single prioritisation board that guides the selection and coordination of our guidance development. We will ask our prioritisation board to consider if guidance should be developed in this area.”

Source location

Response from National Institute for Health and Care Excellence
Page 1 · response
Published 9 May 2024

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