Lack of VTE risk assessment guidance
Department of Health and Social Care received 3 coroners' reports about this hazard between 20 Jan 2023 and 24 Oct 2025.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗
- 6 months laterClosely relatedConfidence 0.90 · higha different coroner
“It is a matter of concern that ward-based nursing staff do not appear to have been provided with clear and unambiguous guidance as to the circumstances when a risk assessment for Venous Thromboembolism ('VTE') should be undertaken following admission to a ward, and the circumstances in which such risk assessment should be repeated.”
Original on judiciary.uk ↗ Repeated from the earlier report:riskVenousThromboembolism
Department of Health and Social Care responded.Response (PDF) ↗
- 2 years 3 months later
Raised again · 2nd time
Sophie Towle↗
24 Oct 2025 · Alexandra Poutney · Nottingham and Nottinghamshire
Closely relatedConfidence 0.90 · higha different coroner“During the course of [the deceased]'s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy.”
Original on judiciary.uk ↗ Repeated from the earlier report:Duringpolicy
Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“ICBs are currently delivering their 3-year strategic plan for commissioning mental health inpatient services. The plans will realise the aims set out in the NHS Mental Health Inpatient Commissioning Framework (NHS England 2024). This Framework is a national guide for how Integrated Care Boards (ICBs) plan inpatient mental health services. It sets out what”
Stated timescale: 2027
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2023 → 2023Corinne Haslam6 months after Sophia Ayuk · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify failures in ensuring proper venous thromboembolism (VTE) risk assessment for inpatients. The earlier report notes that no VTE assessment was performed, while the later report highlights absent clear guidance on when such assessments should be done or repeated.
Sophia Ayuk · 20 Jan 2023
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
Original on judiciary.uk ↗ Corinne Haslam · 21 Jul 2023
“It is a matter of concern that ward-based nursing staff do not appear to have been provided with clear and unambiguous guidance as to the circumstances when a risk assessment for Venous Thromboembolism ('VTE') should be undertaken following admission to a ward, and the circumstances in which such risk assessment should be repeated.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“A VTE Screening and Assessment Clinical Alert was disseminated across the Trust”
2023 → 2025Sophie Towle2 years 9 months after Sophia Ayuk · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports concern deficiencies in venous thromboembolism (VTE) risk assessment linked to trust policy. The earlier report notes missing assessments despite existing policy, while the later report highlights confusion and weakening of the current VTE policy affecting assessments.
Sophia Ayuk · 20 Jan 2023
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
Original on judiciary.uk ↗ Sophie Towle · 24 Oct 2025
“During the course of [the deceased]'s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“A full review of the Trust's VTE policy”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
Stated action · timescale: 2027
“ICBs are currently delivering their 3-year strategic plan for commissioning mental health inpatient services. The plans will realise the aims set out in the NHS Mental Health Inpatient Commissioning Framework (NHS England 2024). This Framework is a national guide for how Integrated Care Boards (ICBs) plan inpatient mental health services. It sets out what”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2023 → 2023 | 0.72 | 0.29 | Closely related · 0.90 | different |
| 2023 → 2025 | 0.80 | 0.19 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.