Francoise Snape
13 Feb 2015 · Coroner Geraint Williams · Worcestershire
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of VTE assessment for stroke patient
“No VTE assessment was ever made of Mrs [name redacted]. The explanation given oy was that staff were too busy to complete the form and that because she had had a stroke heparin could not be given and therefore the Paperwork was unnecessary”
2. non‑adherence to NICE DVT guidance
“NICE guidelines regarding the use of mechanical anti DVT devices instead of heparin in high risk cases was not considered”
3. missed opportunity for appropriate VTE risk management
“absence of a formally completed VTE assessment and lack of knowledge of NICE guidelines amounted to a lost opportunity to make informed decisions for the care of Mrs [name redacted]”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“No VTE assessment was ever made of Mrs [name redacted]. The explanation given oy was that staff were too busy to complete the form”
Later report
“(a) on 2 days ( 10 and 13.2.24 ) no documentation was completed by nurses to show whether Enoxaparin had in fact been administered;”
Closely relatedConfidence 0.90 · high
This report
“No VTE assessment was ever made of Mrs [name redacted]. The explanation given oy was that staff were too busy to complete the form”
Later report
“(b) a venous thromboembolism ( VTE ) assessment was carried out, which identified that the deceased had an identified risk of suffering a VTE event and prescribed compression stockings to mitigate that risk.”
Responses
No published response was found on judiciary.uk.