Lack of VTE assessment and missing anticoagulation documentation
Worcestershire Acute Hospitals NHS Trust received 2 coroners' reports about this hazard between 13 Feb 2015 and 17 Jan 2025.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
No published response from Worcestershire Acute Hospitals NHS Trust was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“No VTE assessment was ever made of Mrs [name redacted]. The explanation given oy was that staff were too busy to complete the form”
Original on judiciary.uk ↗ No published response from Worcestershire Acute Hospitals NHS Trust was found for this report.
- 9 years 11 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“(a) on 2 days ( 10 and 13.2.24 ) no documentation was completed by nurses to show whether Enoxaparin had in fact been administered;”
Original on judiciary.uk ↗ Worcestershire Acute Hospitals NHS Trust responded, stating 5 specific actions.Response (PDF) ↗
“i. Ward managers and Matrons, in their daily safety huddles and team meetings, are reinforcing the direction that staff must sign prescription charts.”
“ii. To update and re-circulate the lesson of the week Trust-wide on mechanical thromboprophylaxis and the importance of signing prescriptions”
3 more stated actions in the Promises tab.
- All reports to Worcestershire Acute Hospitals NHS Trust
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.
2015 → 2025Vauna Leeming9 years 11 months after Francoise Snape · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures to document or administer venous thromboembolism prophylaxis, leading to missed preventive care. The earlier case concerned omission of a VTE assessment; the later case concerned missing documentation of prescribed anticoagulant and stockings.
Francoise Snape · 13 Feb 2015
“No VTE assessment was ever made of Mrs [name redacted]. The explanation given oy was that staff were too busy to complete the form”
Original on judiciary.uk ↗ Vauna Leeming · 17 Jan 2025
“(a) on 2 days ( 10 and 13.2.24 ) no documentation was completed by nurses to show whether Enoxaparin had in fact been administered;”
Original on judiciary.uk ↗
No published response from Worcestershire Acute Hospitals NHS Trust was found for this report.
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 · timescale: monthly
“iii. Divisions will provide monthly VTE compliance reports to the Improving Safety Action Group (ISAG)”
- 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 Worcestershire Acute Hospitals NHS Trust 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 |
|---|---|---|---|---|
| 2015 → 2025 | 0.68 | 0.00 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Worcestershire Acute Hospitals NHS Trust
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.