Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Sophia Ayuk · 20 Jan 2023 · Graeme Irvine, East London
“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.”
judiciary.uk/…/sophia-ayuk-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Sophia Ayuk (20 Jan 2023) · stated timescale: none stated
“A full review of the Trust's VTE policy”
judiciary.uk/…/2023-0022-Response-from-East-London-NHS-Foundati…
Stated action 2 · response to Sophia Ayuk (20 Jan 2023) · stated timescale: none stated
“A VTE Screening and Assessment Clinical Alert was disseminated across the Trust”
judiciary.uk/…/2023-0022-Response-from-East-London-NHS-Foundati…
Stated action 3 · response to Sophia Ayuk (20 Jan 2023) · stated timescale: none stated
“Changes were made to the new doctors' induction and junior doctors handbook to include information on VTE assessments”
judiciary.uk/…/2023-0022-Response-from-East-London-NHS-Foundati…
3 further stated actions are listed on the full chain page.
What recurred
- 12 Aug 2024 · Nimo Osman · Ian Potter · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No evidence found either way · stated action 2
“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”
[PDF] Venous Thromboembolism Prevention - Thrombosis UK · thrombosisuk.org/…/VTE-Prevention-A-Patient-Safety-Priority.pdf
No evidence found does not mean the action did not happen.