Insufficient anticoagulation guidance for immobilised patients
National Institute for Health and Care Excellence received 2 coroners' reports about this hazard between 15 May 2023 and 5 Nov 2024.
They came from 1 coroner. 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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“guidance for clinicians in relation to reducing the risk of DVT when dealing with patients such as Ms [name redacted] who are young and on oral contraception but are immobile following an accident and require surgery is unclear”
Original on judiciary.uk ↗ National Institute for Health and Care Excellence responded, stating 1 specific action.Response (PDF) ↗
“We will request these be addressed as soon as possible”
Stated timescale: as soon as possible
- 1 year 6 months laterClosely relatedConfidence 0.85 · high
“there was no national guidance that would assist clinicians in primary care in assessing whether they should consider prolonging the course of anti- coagulation prescribed in secondary care to reduce the ongoing risk of elderly immobile patients such as Mrs [name redacted] developing a fatal DVT in the community”
Original on judiciary.uk ↗ Repeated from the earlier report:guidancecliniciansriskimmobilepatients
National Institute for Health and Care Excellence responded.Response (PDF) ↗
- All reports to National Institute for Health and Care Excellence
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.
2023 → 2024Audrey Lambert1 year 6 months after Rebekah Mills · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight insufficient clinical guidance regarding anticoagulation management to prevent deep vein thrombosis in immobilised patients.
Rebekah Mills · 15 May 2023
“guidance for clinicians in relation to reducing the risk of DVT when dealing with patients such as Ms [name redacted] who are young and on oral contraception but are immobile following an accident and require surgery is unclear”
Original on judiciary.uk ↗ Audrey Lambert · 5 Nov 2024
“there was no national guidance that would assist clinicians in primary care in assessing whether they should consider prolonging the course of anti- coagulation prescribed in secondary care to reduce the ongoing risk of elderly immobile patients such as Mrs [name redacted] developing a fatal DVT in the community”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We will request these be addressed as soon as possible”
Stated action · timescale: as soon as possible
“We will request these be addressed as soon as possible”
No specific action could be extracted with a verified quote.
- 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 National Institute for Health and Care Excellence 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 |
|---|---|---|---|---|
| 2023 → 2024 | 0.72 | 0.23 | Closely related · 0.85 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.