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recurance

Ann Pearce

28 Nov 2023 · Coroner Joanne Andrews · West Sussex, Brighton and Hove

The coroner's concerns

  1. 1. lack of risk assessment for outpatient DVT

    “Evidence at the inquest revealed that the Venous Thromboembolism Prevention Policy of University Hospitals Sussex NHS Foundation Trust version 1.4 did not make provision for assessment of risk to patients who attended hospital but were not admitted. There was no evidence of any other policy or procedure which did so.”
  2. 2. failure to assess VTE risk post-discharge

    “admission she was immobilised in a brace and on discharge was only partially weight bearing. The Venous Thromboembolism Prevention Policy of University Hospitals Sussex NHS Foundation Trust version 1.4 required that this should be undertaken on admission and reviewed on the daily ward round. No Venous Thromboembolism assessment was undertaken during her admission or on discharge. She became unwell at home on 1 April 2022 and was taken to hospital for treatment but sadly died from a massive pulmonary”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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