John Thorp

Dear Ms Wood, RE: Recommendations following the inquest of John on 15 February 2019 write further t0 the conclusion into inquest of Mr John wherein you had requested the Trust to respond Regulation 28 report you had raised at the conclusion of the inquest The Trust had been asked to respond to the following concerns: Evidence given at the inquest by a senior nurse and Consultant indicated that only a doctor could prescribe TED stockings. There were three different prescriptions for TED in three different areas where Mr Thorpe was treated The Dandarotioard based dstagkhas drug had & tick box in the lower molecular weight heparin box of the drug chart for whether TED stockings were indicated _ 2 Evidence was given at the inquest that the medical staff were inconsistent in how prescribed TED stockings_ One of Mr Thorpe's charts had simply tick in the box indicating were required but there was nowhere for nursing staff to sign if were given , Another chart had separate prescription chart to indicate if had been given, or if not given the reasons why not. 3 There was evidence given that this inconsistency in the way in which medical staff prescribed the TED Stockings may lead to stockings being prescribed but not given which may in turn increase the risk of thromboembolic formation Trust Headquarters: Northwick Fark Fosoital, Watford Road, Harrew, HA1 #v Irwhnhs_Jk
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The Trust is now in a position to respond to your concerns as follows: The Trust has formulated a new; standardised prescription chart to be used across the Trust: The new chart has a section for the prescribing of TED stockings. The Venous Thromboembolism risk assessment is on page 3 of the prescription chart: Once this is completed by the doctor, the nurses will then follow the actions required Where the include the prescribing of TED stockings, this will be written on page qufene presceriptiorcfores "Mechanical Thromboprophylaxis This information will be filled in on daily basis by means of signature and date to indicate that they have checked the of the stockings or devices and checked the integrity of the skin. The actions required have been shared by way of memos to all clinical staff . Junior Doctors have received the instructions via the Medical Education Department: Three separate memos created to ensure the different clinical areas received the information to be acted were upon: This information was also circulated Trust wide in the Trusts' newsletter; The Pulse and as screen saver on Trust desktop computers. This has also been included as part of the Matron $ Quality Walkabout for auditing and monitoring to ensure that this section is completed by the doctors and nurses A copy of the new prescription chart and the memos that were circulated are enclosed as reference We the actions mentioned above are adequate in response to the concerns have raised in your Regulation 28 Order. you