Christine Nakafeero
24 Jul 2023 · Coroner Graeme Irvine · East London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. failure to schedule hysterectomy within 6 months
“Ms [name redacted] was assessed at a Gynae-oncology clinic in early 2019. The patient was diagnosed as not suffering from any form of cancer and was therefore referred on to the”
2. omission of risk factors in VTE assessment
“The clinicians treating Ms [name redacted] assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors which made the formation of a DVT more likely, namely, large uterine fibroids and the use of tranexamic acid.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“the risk assessment requires no consideration of risk factors other than mobility unless 'Step 1' is passed regardless of the number of other risk factors”
This report
“The clinicians treating Ms [name redacted] assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors”