Susan Edwards
4 Jun 2024 · Coroner David Reid · Worcestershire
The coroner's concerns
1. failure to implement mechanical thromboprophylaxis instruction
“On 19 September 2023 a Venous Thromboembolism Risk Assessment made clear that Mrs. [name redacted] should be provided with mechanical thromboprophylaxis. This instruction was not entered on Mrs. [name redacted]' anticoagulation drug card, and Mrs. [name redacted] was not provided with any form of mechanical thromboprophylaxis between that date and her death 18 days later on 7 October 2023. No nurse or reviewing doctor picked up on this omission.”
Responses
2024-0303-Response-from-Worcestershire-Acute-Hospitals-NHS-Trust.pdf ↗· Worcestershire Acute Hospitals NHS Trust
Stated action
“There will be a Lesson of the week around what constitutes both o hosiery and mechanical prophylaxis, and it will be reiterated to staff that they must sign the prescription chart to confirm that this prophylaxis is on/in place”