Gordon Thornhill
4 Dec 2017 · Coroner Nicola Mundy · South Yorkshire (East)
The coroner's concerns
1. incomplete mandatory VTE risk assessment
“Junior doctor's failure to fully complete the mandatory VTE risk assessment”
2. failure to identify incomplete VTE risk assessment
“Consultant's VTE assessment done the day following admission failed to identify incomplete/failure to complete VTE risk assessment”
3. lack of documented consultant assessment
“Consultant carried out his own assessment as a "mental exercise" and did not document his assessment”
4. delay in providing thromboprophylaxis
“A delay in excess of 24 hours in providing thromboprophylaxis”
Responses
2017-0359-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Trust.pdf ↗· Doncaster Royal Infirmary
Stated action · July 2014
“The Trust has a policy entitled Venous Thromboembolysm (VTE) - Prevention and Treatment of VTE in Patients Admitted to Hospital. This policy is available on the intranet and has been in place since July 2014. It is currently being reviewed to take into consideration the changes within the organisation but the essence of the prevention policy will remain intact. The policy clearly identifies the role that individuals have in assessing and ensuring that patients receive the appropriate prophylaxis”