Vivien Brunning
12 Oct 2021 · Coroner Graeme Irvine · East London
The coroner's concerns
1. lack of required VTE reviews
“required venous thromboembolism reviews at 24 & 72 hrs following admission were not undertaken”
2. omission of prescribed low molecular weight heparin
“Prescribed daily injections of low molecular weight heparin were omitted on 13 and 14" July 2020”
3. failure to report omission through incident reporting system
“The initial omission on 13" July 2020 was noticed by a ward doctor but was not reported through the Trust's incident reporting system”