Incomplete venous thromboembolism risk assessment
East London NHS Foundation Trust received 2 coroners' reports about this hazard between 20 Jan 2023 and 12 Aug 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 6 specific actions.
The story, report by report
Spacing grows with the time between reports.
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
Original on judiciary.uk ↗ East London NHS Foundation Trust responded, stating 6 specific actions.Response (PDF) ↗
“A full review of the Trust's VTE policy”
“A VTE Screening and Assessment Clinical Alert was disseminated across the Trust”
Web search (Tavily): No evidence found either way
[PDF] Venous Thromboembolism Prevention - Thrombosis UK ↗4 more stated actions in the Promises tab.
- 1 year 7 months laterIdentical hazardConfidence 0.90 · higha different coroner
“As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.”
Original on judiciary.uk ↗ Repeated from the earlier report:Policyriskin-patient
East London NHS Foundation Trust responded.Response (PDF) ↗
- All reports to East London NHS Foundation Trust
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 → 2024Nimo Osman1 year 7 months after Sophia Ayuk · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that patients were not receiving the required venous thromboembolism (VTE) risk assessment during inpatient care. The later report notes that the VTE assessment policy has not been fully embedded, leaving the same hazard unresolved.
Sophia Ayuk · 20 Jan 2023
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
Original on judiciary.uk ↗ Nimo Osman · 12 Aug 2024
“As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“A VTE Screening and Assessment Clinical Alert was disseminated across the Trust”
Stated action
“A full review of the Trust's VTE policy”
Stated action
“A VTE Screening and Assessment Clinical Alert was disseminated across the Trust”
What happened next: No evidence found either way
The Trust's policy and procedure page indicates that policies are added when approved, but no specific mention of a VTE screening alert is provided. The document lists various policies but does not reference the promised clinical alert.
“Venous Thromboembolism Prevention A Patient Safety Priority Edited by Dr [name redacted] BMBCh MA PhD FRCP FRCPath Director, King's Thrombosis Centre Lead for the National Exemplar Centre Initiative Published by: In conjunction with: Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Professor”
No evidence found does not mean the action did not happen.
Stated action
“Changes were made to the new doctors' induction and junior doctors handbook to include information on VTE assessments”
Stated action
“Anti-psychotic medication has been added as a consideration on the Trust's VTE assessment tool”
Stated action
“The Trust's monthly two day physical health training programme now includes a session on VTE risk”
Stated action
“A yellow card warning was raised with the manufacturers of the anti-psychotic, Zaponex through the Medicines Health Regulations Authority (MHRA) to alert to two patients who have both passed away from pulmonary embolism whilst on Zaponex”
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 East London NHS Foundation Trust 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 | 0.69 | 0.21 | 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 East London NHS Foundation Trust
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.