PFD report

Mary Barbara Ryder · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 27 Sep 2018•Manchester South

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
1

Of 1 recipient

Stated actions
0

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 emphasise review of post-operative prophylaxis after discharge home
    Part of recurring concern: Failure to provide timely and adequate follow-up after dischargePart of recurring concern: Unreliable post-operative monitoring and clinical review
  2. Lack of guidance for extending clexane prophylaxis when patient mobility remains reduced
    Part of recurring concern: Inadequate thromboprophylaxis for patients at risk of venous thromboembolism
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    NICE concluded that its VTE guidelines are appropriate and require no amendment at this time.

    Stated by Department of Health and Social CareNo action considered necessaryThe respondent said that 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

Failure to emphasise review of post-operative prophylaxis after discharge home

Wider context from the report

“The inquest heard that: The guidance nationally is to prescribe clexane for 28 days after an operation. However, the guidance does not suggest that some cases may require longer where a patients mobility remains reduced. There does not appear to be an emphasis on the need to review the situation throughout the post-operative period after a discharge home. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge; Unreliable post-operative monitoring and clinical review.

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

Lack of guidance for extending clexane prophylaxis when patient mobility remains reduced

Wider context from the report

“The inquest heard that: The guidance nationally is to prescribe clexane for 28 days after an operation. However, the guidance does not suggest that some cases may require longer where a patients mobility remains reduced. There does not appear to be an emphasis on the need to review the situation throughout the post-operative period after a discharge home. ”

Is this part of a recurring concern?

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

Open source report

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 concluded that its VTE guidelines are appropriate and require no amendment at this time.

Verbatim wording from the response

“My officials have made enquiries with the National Institute for Health and Care Excellence (NICE) on the matter of concern you have raised.”

Source location

2018-0323-Response-by-Department-of-Health-Social-Care
Page 1 · response
Published 24 February 2019

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