PFD report

Gordon Frank Thornhill · Prevention of Future Deaths report

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Issued 4 Dec 2017•South Yorkshire (Eastern)

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised4

  1. Delays in providing thromboprophylaxis exceeding 24 hours
    Part of recurring concern: Inadequate thromboprophylaxis for patients at risk of venous thromboembolism
  2. Failure to fully complete mandatory VTE risk assessments
  3. Failure of consultant VTE assessment to identify incomplete VTE risk assessments
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

    Advise consultants and associate specialists to ensure VTE assessments are completed and documented during post-take ward rounds and to support trainees.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  2. Action

    Re-launch the Stop the Clot campaign through ward and education-centre posters, internal communications, and intranet messaging about VTE assessment and prophylaxis.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.
  3. Action

    Reinforce the importance of prescribing VTE prophylaxis promptly.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.

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

Delays in providing thromboprophylaxis exceeding 24 hours

Wider context from the report

“(4) A delay in excess of 24 hours in providing thromboprophylaxis. ”

Is this part of a recurring concern?

Yes — Inadequate thromboprophylaxis for patients at risk of venous thromboembolism.

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 fully complete mandatory VTE risk assessments

Wider context from the report

“(1) Junior doctor's failure to fully complete the mandatory VTE risk assessment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 of consultant VTE assessment to identify incomplete VTE risk assessments

Wider context from the report

“(2) The Consultant’s VTE assessment done the day following admission failed to identify incomplete/failure to complete VTE risk assessment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 document consultant VTE assessments

Wider context from the report

“(3) The Consultant carried out his own assessment as a “mental exercise” and did not document his assessment. ”

Is this part of a recurring concern?

Yes — Unreliable documentation of safety risk assessments.

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

Advise consultants and associate specialists to ensure VTE assessments are completed and documented during post-take ward rounds and to support trainees.

Verbatim wording from the response

“2. I am advised by the Director of Education that VTE prophylaxis is addressed at induction and there is an electronic package approved by Health Education England which trainees have to complete for their annual review (ARCP). This is monitored through the post graduate schools on behalf of Health Education England. This should be supplemented by on-site support and monitoring by consultants. In light of the events that you highlight I have personally written to all consultants and associate specialists advising them of the importance of ensuring that VTE assessments are completed and documented on the post-take ward round and to that end to provide the required support for trainees.”

Source location

2017-0359-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 11 February 2018

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

Re-launch the Stop the Clot campaign through ward and education-centre posters, internal communications, and intranet messaging about VTE assessment and prophylaxis.

Verbatim wording from the response

“6. Finally the Trust is in the process of re-launching the “Stop the Clot” campaign which was successful in the early years in ensuring VTE prophylaxis was appropriately undertaken and in a timely manner. This will include strategically placed posters in ward areas and the education centre as well as use of the Trust’s communication systems (Buzz, Risky Business) to highlight the importance of risk assessment and prescription of prophylaxis. The same message will be on the Intranet.”

Source location

2017-0359-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 11 February 2018

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

Reinforce the importance of prescribing VTE prophylaxis promptly.

Verbatim wording from the response

“4. The Trust has a system of medicines reconciliation for acute admissions on the medical assessment unit and the pharmacists are actively involved in ensuring that this process runs smoothly and also highlighting whether prophylaxis has been prescribed. On this occasion the prophylaxis was prescribed but due to human error it was prescribed to commence on the following day. The message of timely prescription has been reinforced.”

Source location

2017-0359-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 11 February 2018

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 medical assessment unit quality-improvement project to improve completion and review of VTE assessments and timely prophylaxis prescribing and administration.

Verbatim wording from the response

“5. I am advised by the VTE Lead for the Trust that there is currently a quality improvement project being undertaken on the medical assessment unit to ensure greater compliance with the medical VTE risk assessment form and to ensure that this is reviewed on the post-take ward round and where appropriate prophylaxis is actually prescribed and given in a timely manner.”

Source location

2017-0359-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 11 February 2018

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.1

  1. 1

    Review the VTE prevention policy to reflect organisational changes while retaining its prevention requirements.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.

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

  1. 1

    Existing VTE policies and processes are considered sufficient to ensure doctors assess and prescribe thromboprophylaxis appropriately.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Review the VTE prevention policy to reflect organisational changes while retaining its prevention requirements.

Verbatim wording from the response

“1. The Trust has a policy entitled Venous Thromboembolism (VTE) – Prevention and Treatment of VTE in Patients Admitted to Hospital. This policy is available on the intranet and has been in place since July 2014. It is currently being reviewed to take”

Source location

2017-0359-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Trust
Page 1 · response
Published 11 February 2018

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 VTE policies and processes are considered sufficient to ensure doctors assess and prescribe thromboprophylaxis appropriately.

Verbatim wording from the response

“consideration the changes within the organisation but the essence of the prevention policy will remain intact. The policy clearly identifies the role that individuals have in assessing and ensuring that patients receive the appropriate prophylaxis. I enclose a copy of the policy.”

Source location

2017-0359-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 11 February 2018

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