Vauna Leeming

Dear Mr Reid

Re Regulation 28 Report to Prevent Future Deaths

Please accept this letter in response to your Regulation 28 Report to Prevent Future Deaths received on the 15th January 2025, following the Inquest on the death of Vauna Leeming.

In your Regulation 28 report, you identified the following matters of concern relating to the Worcestershire Acute Hospitals NHS Trust (WAHT).

1) You were concerned that there is still insufficient awareness among employed and agency nurses at the Trust of their professional duty:

(a) to complete important documentation such as prescription charts and

(b) to report any omissions in the completion of such documentation to a senior colleague

The Chief Medical Officer (CMO) requested an Extra-Ordinary VTE meeting to discuss Ms Leemings case, the concerns raised by yourself, and to assess our own level of assurance around compliance relating to VTE prophylaxis. There were a number of measures agreed including:

• It was agreed and confirmed that mechanical thromboprophylaxis (TEDS/compression stockings) remain the best option if the patient was unable to receive pharmacological thromboprophylaxis (such as Enoxaparin)

• To increase the monitoring of VTE compliance via our Improving Safety Action Group (ISAG), chaired by the Chief Nursing Officer/CMO.

Chief Executive Worcester Royal Hospital Charles Hastings Way Worcester WR5 1DD

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Chair:

Chief Executive:

The Trust is committed to being environmentally friendly, therefore where possible we use 100% recycled paper. This paper has been made using no harmful chemicals in the manufacturing process. In response to your specific concerns listed above please find below the actions the trust have taken:

1a)

i. Ward managers and Matrons, in their daily safety huddles and team meetings, are reinforcing the direction that staff must sign prescription charts.

ii. To update and re-circulate the lesson of the week Trust-wide on mechanical thromboprophylaxis and the importance of signing prescriptions

iii. The CMO will write to the digital team creating the electronic medical prescribing charts, formally requesting that they ensure that the new charts meet all requirements, prior to being launched (e.g. prescribing of TEDS)

1b)

i. There is a question (see below) on the weekly quality checks that are completed by ward managers and matrons, this is not always utilised if the question was not applicable to that patient (as not every patient on every ward is audited). This would be an opportunity for ward managers to highlight and escalate accordingly any gaps or omissions.

QUESTION: Has mechanical VTE prophylaxis been prescribed (TED stockings/boot) QUESTION: If prescribed, has the mechanical VTE prophylaxis been signed on the chart as 'in place'?

ii. Therefore, each division will undertake local regular audits, to check compliance with signing prescription charts
iii. Divisions will provide monthly VTE compliance reports to the Improving Safety Action Group (ISAG)

Please let me know if you require any further information.