Nicola Tweedy
12 Mar 2015 · Coroner Jacqueline Lake · Norfolk
The coroner's concerns
1. lack of procedure aftercare leaflets
“Specific leaflets relating to the procedure and aftercare were not handed to the patient”
2. incomplete risk assessment for thromboprophylaxis
“The Thromboprophylaxis Risk Assessment form was not completed at any point throughout Mrs [name redacted] dealings with the hospital”
3. incomplete discharge nursing notes
“Nursing notes on discharge did not fully cover all the factors required to be checked before a patient is discharged”
4. nurse not seeing patient before discharge
“There was no evidence that the Nurse completing the notes had actually seen Mrs [name redacted] prior to discharge”
5. incomplete discharge checklist
“The checklist Form for completion on discharge was not completed”
Responses
2015-0095-Response-by-Department-of-Health.pdf ↗· Norfolk and Norwich University Hospital NHS Foundation Trust
Stated action · 2010
“The Department is aware of the importance of reducing the risk of venous thromboembolism (VTE) in hospital patients and the need for all nurses and health care assistants to understand VTE prevention procedures, and the reasons for these procedures. This is why the Department recommends use of a risk assessment checklist and published a VTE risk assessment tool in 2010”
2015-0095-Response-by-Norfolk-Norwich-University-Hospitals.pdf ↗· Norfolk and Norwich University Hospital NHS Foundation Trust