PFD report

Joseph Arthur Charles · Prevention of Future Deaths report

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Issued 6 Aug 2019•North London

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
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
7

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 raised1

  1. Lack of recommendations or guidance for prevention of DVT and pulmonary embolus in upper limb surgery
    Part of recurring concern: Inadequate thromboprophylaxis for patients at risk of venous thromboembolismPart of recurring concern: Unreliable DVT diagnosis and management
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

    Deliver education and awareness sessions on the VTE policy and publicise policy and guideline updates through orthopaedic governance and audit meetings.

    Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
  2. Action

    Add a thromboprophylaxis domain to the local pre-operative checklist to prompt anaesthetists to record prophylaxis on the anaesthetic drug chart.

    Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
  3. Action

    Discuss the revised pre-operative checklist process with the Head of Anaesthetics.

    Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Existing local VTE guidance requires no amendment because it is consistent with national guidance and covers major elbow surgery.

    Stated by Royal Free London 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

Lack of recommendations or guidance for prevention of DVT and pulmonary embolus in upper limb surgery

Wider context from the report

“That although there are clear National guidelines for the prevention of DVT and pulmonary embolus there are no such recommendations or guidance for upper limb surgery. ”

Is this part of a recurring concern?

Yes — Inadequate thromboprophylaxis for patients at risk of venous thromboembolism; Unreliable DVT diagnosis and management.

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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

Deliver education and awareness sessions on the VTE policy and publicise policy and guideline updates through orthopaedic governance and audit meetings.

Verbatim wording from the response

“Review of the Trust’s Venous Thromboembolism (VTE) prevention policy It was agreed there is no need to amend or change the present guidance, which is consistent with national guidelines for lower limb surgery and specifically mentions any major surgery over 90 minutes, which would include the elbow replacement surgery which Mr. Charles had. However, there is now an opportunity to strengthen education, training and awareness of this policy is amongst the surgical team. ████████ Consultant Haematologist, is to conduct an education and awareness event at the next Orthopaedic Governance Meeting on Tuesday 1 October 2019, and in addition there will be an audit meeting to publicise the policy and guidelines updates on Tuesday 3 December 2019.”

Source location

2019-0277-Response-by-North-Middlesex-Hospital
Page 1 · response
Published 18 October 2019

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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

Add a thromboprophylaxis domain to the local pre-operative checklist to prompt anaesthetists to record prophylaxis on the anaesthetic drug chart.

Verbatim wording from the response

“Review of the VTE risk assessment in theatres Although appropriate risk assessments are undertaken prior to routine surgery, our investigation revealed that the required medication(VTE prophylaxis) in this case had not always been prescribed. As such, an extra domain has been added to our local pre-operative checklist to ensure that the anaesthetists will write up thromboprophylaxis on the anaesthetic drug chart during surgery. This change in process will be discussed with the Head of Anaesthetics by 31 October 2019.”

Source location

2019-0277-Response-by-North-Middlesex-Hospital
Page 2 · response
Published 18 October 2019

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

Discuss the revised pre-operative checklist process with the Head of Anaesthetics.

Verbatim wording from the response

“Review of the VTE risk assessment in theatres Although appropriate risk assessments are undertaken prior to routine surgery, our investigation revealed that the required medication(VTE prophylaxis) in this case had not always been prescribed. As such, an extra domain has been added to our local pre-operative checklist to ensure that the anaesthetists will write up thromboprophylaxis on the anaesthetic drug chart during surgery. This change in process will be discussed with the Head of Anaesthetics by 31 October 2019.”

Source location

2019-0277-Response-by-North-Middlesex-Hospital
Page 2 · response
Published 18 October 2019

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

Incorporate the approved VTE risk-assessment leaflet into the revised Orthopaedics Handbook.

Verbatim wording from the response

“Publishing a VTE risk assessment template/flyer in Orthopaedics Discussions are currently being held by the hospital’s Thrombosis Group regarding the publishing of a new leaflet, which is due for Trust-wide implementation by 31 January 2020. Following approval this leaflet will be incorporated into the Orthopaedics Handbook, which is due to be revised by 28 February 2020.”

Source location

2019-0277-Response-by-North-Middlesex-Hospital
Page 2 · response
Published 18 October 2019

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

Existing local VTE guidance requires no amendment because it is consistent with national guidance and covers major elbow surgery.

Verbatim wording from the response

“Review of the Trust’s Venous Thromboembolism (VTE) prevention policy It was agreed there is no need to amend or change the present guidance, which is consistent with national guidelines for lower limb surgery and specifically mentions any major surgery over 90 minutes, which would include the elbow replacement surgery which Mr. Charles had. However, there is now an opportunity to strengthen education, training and awareness of this policy is amongst the surgical team. ████████ Consultant Haematologist, is to conduct an education and awareness event at the next Orthopaedic Governance Meeting on Tuesday 1 October 2019, and in addition there will be an audit meeting to publicise the policy and guidelines updates on Tuesday 3 December 2019.”

Source location

2019-0277-Response-by-North-Middlesex-Hospital
Page 1 · response
Published 18 October 2019

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

Responsibility for addressing the lack of national DVT and pulmonary embolus prevention guidelines lies with the Department of Health.

Verbatim wording from the response

“We write following receipt of the Regulation 28 report issued following the conclusion of the inquest into the death of the above named. Whilst we understand that the lack of national guidelines for the prevention of DVT and pulmonary embolus following upper limb surgery is a matter for the Department of Health to address, the Trust decided to undertake a review of our local policy and procedures.”

Source location

2019-0277-Response-by-North-Middlesex-Hospital
Page 1 · response
Published 18 October 2019

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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.3

  1. 1

    Publish a new VTE risk-assessment leaflet for Trust-wide implementation.

    Stated by Royal Free London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
  2. 2

    Add a mandatory VTE risk-assessment summary step to the electronic discharge procedure before patients can be discharged.

    Stated by Royal Free London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
  3. 3

    Undertake a further VTE risk assessment for all inpatient and day-case surgical patients before discharge.

    Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    There were no failures in the care and treatment provided during or after the surgery.

    Stated by Royal Free London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 a new VTE risk-assessment leaflet for Trust-wide implementation.

Verbatim wording from the response

“Publishing a VTE risk assessment template/flyer in Orthopaedics Discussions are currently being held by the hospital’s Thrombosis Group regarding the publishing of a new leaflet, which is due for Trust-wide implementation by 31 January 2020. Following approval this leaflet will be incorporated into the Orthopaedics Handbook, which is due to be revised by 28 February 2020.”

Source location

2019-0277-Response-by-North-Middlesex-Hospital
Page 2 · response
Published 18 October 2019

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

Add a mandatory VTE risk-assessment summary step to the electronic discharge procedure before patients can be discharged.

Verbatim wording from the response

“All inpatient and day case surgery patients to be risk assessed on discharge In addition to the Risk Assessment for VTE, which is carried out for all patients on admission, a further risk assessment is now undertaken on surgical patients prior to discharge. This has been implemented with immediate effect. The orthopaedic team are also working with the Information Technology (IT) department in order to introduce an additional step to the electronic discharge procedure, whereby there will be a requirement to complete the VTE risk assessment summary”

Source location

2019-0277-Response-by-North-Middlesex-Hospital
Page 1 · response
Published 18 October 2019

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

Undertake a further VTE risk assessment for all inpatient and day-case surgical patients before discharge.

Verbatim wording from the response

“All inpatient and day case surgery patients to be risk assessed on discharge In addition to the Risk Assessment for VTE, which is carried out for all patients on admission, a further risk assessment is now undertaken on surgical patients prior to discharge. This has been implemented with immediate effect. The orthopaedic team are also working with the Information Technology (IT) department in order to introduce an additional step to the electronic discharge procedure, whereby there will be a requirement to complete the VTE risk assessment summary”

Source location

2019-0277-Response-by-North-Middlesex-Hospital
Page 1 · response
Published 18 October 2019

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

There were no failures in the care and treatment provided during or after the surgery.

Verbatim wording from the response

“We can confirm that there were no failures in the care and treatment that Mr Charles received either during or following his right elbow surgery. However, we felt it was important to ensure that, in the absence of any national guidelines, our local guidelines for prevention of DVT following upper limb surgery are robust, and improvements to ensure safety netting are made wherever possible. As a result of this review, the following actions have been carried out:”

Source location

2019-0277-Response-by-North-Middlesex-Hospital
Page 1 · response
Published 18 October 2019

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