Risk assessment tool overlooks DVT risk factors
Department of Health and Social Care received 2 coroners' reports about this hazard between 19 Feb 2021 and 23 Apr 2024.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Evidence emerged during the inquest that both the consulting Psychiatrist and the Hospital's Manager said that Ms [name redacted] was assessed upon admission to hospital in accordance with the national guidelines for the assessment for Deep vein thrombosis (DVT).”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗
- 3 years 2 months laterIdentical hazardConfidence 0.90 · higha different coroner
“Despite evidence to suggest that mobility is not the ultimate deciding factor of risk of DVT, the risk assessment tool as currently drafted and relied upon by clinicians would suggest that there is no further need for assessment.”
Original on judiciary.uk ↗ Repeated from the earlier report:evidenceassessment
Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The Department will work with NHS England to consider the VTE risk assessment tool, in light of the concerns you have raised.”
“we recommend that clinicians should use 'a tool published by a national UK body, professional network or peer-reviewed journal' to assess VTE risk, however we do not recommend a particular risk assessment tool as there is not enough evidence to support the use of one over another”
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2021 → 2024Nuliyati Businje3 years 2 months after Lisa Grant · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that relying solely on reduced mobility to decide against DVT assessment misses other risk factors. They concern the same flaw in the risk assessment tool/guidance.
Lisa Grant · 19 Feb 2021
“Evidence emerged during the inquest that both the consulting Psychiatrist and the Hospital's Manager said that Ms [name redacted] was assessed upon admission to hospital in accordance with the national guidelines for the assessment for Deep vein thrombosis (DVT).”
Original on judiciary.uk ↗ Nuliyati Businje · 23 Apr 2024
“Despite evidence to suggest that mobility is not the ultimate deciding factor of risk of DVT, the risk assessment tool as currently drafted and relied upon by clinicians would suggest that there is no further need for assessment.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
Stated action
“The Department will work with NHS England to consider the VTE risk assessment tool, in light of the concerns you have raised.”
Stated action
“we recommend that clinicians should use 'a tool published by a national UK body, professional network or peer-reviewed journal' to assess VTE risk, however we do not recommend a particular risk assessment tool as there is not enough evidence to support the use of one over another”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2021 → 2024 | 0.70 | 0.11 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Department of Health and Social Care
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.