Vauna Leeming
17 Jan 2025 · Coroner David Reid · Worcestershire
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. incomplete documentation of prescribed anticoagulation and compression stockings
“Following Mrs. [name redacted] surgery on 8.2.24, measures were put in place to prevent the formation of a deep vein thrombosis and/or pulmonary embolism. Those measures were prescriptions for anticoagulation medication ( Enoxaparin ) and for compression stockings. The inquest heard evidence that over the 46 days between the surgery and Mrs. [name redacted] death: (a) on 2 days ( 10 and 13.2.24 ) no documentation was completed by nurses to show whether Enoxaparin had in fact been administered; and (b) on a”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“No VTE assessment was ever made of Mrs [name redacted]. The explanation given oy was that staff were too busy to complete the form”
This report
“(a) on 2 days ( 10 and 13.2.24 ) no documentation was completed by nurses to show whether Enoxaparin had in fact been administered;”
Responses
2025-0033-Response-from-Worcestershire-Acute-Hospitals-NHS-Trust-.pdf ↗· Worcestershire Acute Hospitals NHS Trust
Stated action
“i. Ward managers and Matrons, in their daily safety huddles and team meetings, are reinforcing the direction that staff must sign prescription charts.”
Stated action
“ii. To update and re-circulate the lesson of the week Trust-wide on mechanical thromboprophylaxis and the importance of signing prescriptions”
Stated action
“iii. The CMO will write to the digital team creating the electronic medical prescribing charts, formally requesting that they ensure that the new charts meet all requirements, prior to being launched (e.g. prescribing of TEDS)”
Stated action
“ii. Therefore, each division will undertake local regular audits, to check compliance with signing prescription charts”
Stated action · monthly
“iii. Divisions will provide monthly VTE compliance reports to the Improving Safety Action Group (ISAG)”