Recurance · prevention of future deaths reports
Pre-inquest brief
Risk assessment tool overlooks DVT risk factors
The earlier warning
Lisa Grant · 19 Feb 2021 · Zafar Siddique, Black Country
“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).”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 23 Apr 2024 · Nuliyati Businje · Victoria Davies · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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).”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.