Sophia Ayuk
20 Jan 2023 · Coroner Graeme Irvine · East London
This report repeats 1 earlier warning, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. lack of VTE risk assessment
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
2. inadequate monitoring of food and fluid intake
“Instructions given to monitor and record Ms [name redacted] food and fluid intake were not adequately followed.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate.”
This report
“Instructions given to monitor and record Ms [name redacted] food and fluid intake were not adequately followed.”
Closely relatedConfidence 0.90 · high
This report
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
Later report
“It is a matter of concern that ward-based nursing staff do not appear to have been provided with clear and unambiguous guidance as to the circumstances when a risk assessment for Venous Thromboembolism ('VTE') should be undertaken following admission to a ward, and the circumstances in which such risk assessment should be repeated.”
Identical hazardConfidence 0.90 · high
This report
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
Later report
“As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.”
Closely relatedConfidence 0.90 · high
This report
“At no time during the two periods of Ms [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.”
Later report
“During the course of [the deceased]'s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy.”
Responses
2023-0022-Response-from-East-London-NHS-Foundation-Trust-.pdf ↗· East London NHS Foundation Trust
Stated action
“A full review of the Trust's VTE policy”
Stated action
“A VTE Screening and Assessment Clinical Alert was disseminated across the Trust”
Stated action
“Changes were made to the new doctors' induction and junior doctors handbook to include information on VTE assessments”
Stated action
“Anti-psychotic medication has been added as a consideration on the Trust's VTE assessment tool”
Stated action
“The Trust's monthly two day physical health training programme now includes a session on VTE risk”
Stated action
“A yellow card warning was raised with the manufacturers of the anti-psychotic, Zaponex through the Medicines Health Regulations Authority (MHRA) to alert to two patients who have both passed away from pulmonary embolism whilst on Zaponex”