Jonathan Kingsman
13 Jul 2021 · Coroner Simon Milburn · Cambridgeshire & Peterborough
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. failure to assess VTE risk
“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 which may be present and their severity - Mr [name redacted] was not obviously at risk of 'significantly increased immobility compared to his normal state' but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future;”
2. lack of guidance and definitions
“The risk assessment form contains no guidance on its completion and no definition of certain terms.”
Linked reports
Identical hazardConfidence 0.90 · high
This 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”
Later 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”
Responses
2021-0238-Response-from-Department-of-Health-Social-Care_Published.pdf ↗· Department of Health and Social Care
Stated action
“my officials have made enquiries with NHS England and NHS Improvement (NHSEI), and the National Institute for Health and Care Excellence (NICE)”