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recurance

Susan Edwards

4 Jun 2024 · Coroner David Reid · Worcestershire

The coroner's concerns

  1. 1. failure to implement mechanical thromboprophylaxis instruction

    “On 19 September 2023 a Venous Thromboembolism Risk Assessment made clear that Mrs. [name redacted] should be provided with mechanical thromboprophylaxis. This instruction was not entered on Mrs. [name redacted]' anticoagulation drug card, and Mrs. [name redacted] was not provided with any form of mechanical thromboprophylaxis between that date and her death 18 days later on 7 October 2023. No nurse or reviewing doctor picked up on this omission.”

Responses

2024-0303-Response-from-Worcestershire-Acute-Hospitals-NHS-Trust.pdf ↗· Worcestershire Acute Hospitals NHS Trust

Stated action

“There will be a Lesson of the week around what constitutes both o hosiery and mechanical prophylaxis, and it will be reiterated to staff that they must sign the prescription chart to confirm that this prophylaxis is on/in place”
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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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