Recurance · prevention of future deaths reports
Pre-inquest brief
Insufficient anticoagulation guidance for immobilised patients
The earlier warning
Rebekah Mills · 15 May 2023 · Alison Mutch, Manchester South
“guidance for clinicians in relation to reducing the risk of DVT when dealing with patients such as Ms [name redacted] who are young and on oral contraception but are immobile following an accident and require surgery is unclear”
judiciary.uk/…/rebekah-mills-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Rebekah Mills (15 May 2023) · stated timescale: as soon as possible
“We will request these be addressed as soon as possible”
judiciary.uk/…/2023-0152-Response-from-Medicines-Healthcare-pro…
What recurred
- 5 Nov 2024 · Audrey Lambert · Alison Mutch · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Rebekah Mills · 15 May 2023
“guidance for clinicians in relation to reducing the risk of DVT when dealing with patients such as Ms [name redacted] who are young and on oral contraception but are immobile following an accident and require surgery is unclear”
Later · Audrey Lambert · 5 Nov 2024
“there was no national guidance that would assist clinicians in primary care in assessing whether they should consider prolonging the course of anti- coagulation prescribed in secondary care to reduce the ongoing risk of elderly immobile patients such as Mrs [name redacted] developing a fatal DVT in the community”
What happened next
No web check of the stated actions has been published for this chain.