Dorothy Strickley
31 Oct 2018 · Coroner Lydia Brown · Leicester City and Leicestershire South
The coroner's concerns
1. failure to provide anti-embolic stockings at discharge
“A basic and routine prescription for AES was not successfully brought to the patient's attention at the time of discharge and Mrs [name redacted] was unaware of the need to continue to wear stockings until she returned to her usual daily activity level. She died from the ver com lication that the stockin s would have hel ed to revent.”
2. lack of discharge-specific thromboprophylaxis guidelines
“The local Guidelines for Pharmacological and Mechanical Thromboprophylaxis for venous thromboembolism does not cover patient discharge from hospital, although the importanc”
3. failure of nursing and surgical teams to ensure provision and education on anti-embolic stockings
“There was a failure of both nursing and surgical teams to ensure AES were provided and the patient and/or her family were advised of the correct use.”
4. need for staff training and documentation review
“Further training may therefore be considered necessary, together with a review of the documentation such as the nursing discharge tool.”
5. local policy not aligned with NICE guidelines
“The current local policy does not reflect NICE guidelines in full.”