Continuing medication for VTE risk after discharge
National Institute for Health and Care Excellence received 2 coroners' reports about this hazard between 29 Nov 2019 and 27 Oct 2023.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from National Institute for Health and Care Excellence was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“I am concerned that the various medical practitioners who attended upon Mrs [name redacted] did not consider continuing prescribing Mrs [name redacted] medication to minimise the risk of VTE after her discharge from hospital on 21st December 2018”
Original on judiciary.uk ↗ No published response from National Institute for Health and Care Excellence was found for this report.
- 3 years 11 months laterIdentical hazardConfidence 0.90 · higha different coroner
“There seems to be a lack of clarity amongst health and care professionals (certainly those who gave evidence at this inquest) as to whether community organisations receiving patients following discharge from hospital”
Original on judiciary.uk ↗ Repeated from the earlier report:dischargehospital
National Institute for Health and Care Excellence responded, stating 1 specific action.Response (PDF) ↗
“we propose to review the guideline to see if it can be updated to cover the issue of continuing VTE prophylaxis on discharge so that inpatient anticoagulation prescriptions for VTE prophylaxis are converted to ongoing anticoagulation where required”
- All reports to National Institute for Health and Care Excellence
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.
2019 → 2023Andrew Nichols3 years 11 months after Brenda McWilliams · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that venous thromboembolism risk after hospital discharge is not being adequately managed due to uncertainty about who should assess or continue prophylaxis.
Brenda McWilliams · 29 Nov 2019
“I am concerned that the various medical practitioners who attended upon Mrs [name redacted] did not consider continuing prescribing Mrs [name redacted] medication to minimise the risk of VTE after her discharge from hospital on 21st December 2018”
Original on judiciary.uk ↗ Andrew Nichols · 27 Oct 2023
“There seems to be a lack of clarity amongst health and care professionals (certainly those who gave evidence at this inquest) as to whether community organisations receiving patients following discharge from hospital”
Original on judiciary.uk ↗
No published response from National Institute for Health and Care Excellence was found for this report.
Stated action
“we propose to review the guideline to see if it can be updated to cover the issue of continuing VTE prophylaxis on discharge so that inpatient anticoagulation prescriptions for VTE prophylaxis are converted to ongoing anticoagulation where required”
- 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 National Institute for Health and Care Excellence 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 |
|---|---|---|---|---|
| 2019 → 2023 | 0.66 | 0.13 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for National Institute for Health and Care Excellence
- Inadequate shift handover communication leading to missed critical patient details2 reports · 2019–2026
- Inconsistent interpretation of antenatal CTG leading to delayed response2 reports · 2014–2025
- Insufficient anticoagulation guidance for immobilised patients2 reports · 2023–2024
- Inadequate diabetes screening guidance for healthcare professionals2 reports · 2015–2019
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.