University Hospitals of Leicester
NHS / Health Body
Action Taken
Following concerns raised, the Clinical Management Group undertook an exercise with the medical team to reinforce the importance of good communication. Additionally, a Task and Finish Group was established to review VTE management, UHL guidance, written discharge information, thromboprophylaxis practice, training, governance, and develop a Standard Operating Procedure. A VTE Learning Bulletin was issued to all clinical staff, reiterating guidelines for Thromboprophylaxis for VTE and lessons learned. (AI summary)
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Dear Mrs Brown Re Dorothy Joan STRICKLEY Thank you for your letter of 31St October 2018 sent following the issue of a Regulation 28 Report. I am now in a position to respond. Where it is intended that a patient such as Mrs Strickley is to be discharged with Anti-Embolic Stockings (AES) there needs to be clear communication about this issue within the clinical team caring for the patient. Regrettably this did not occur on this occasion and I am sorry that this was so. am able to confirm that the Clinical Management Group that cared for Mrs Strickley has undertaken an exercise with relevant members of the treating medical team, led by the Clinical Director, to ensure appropriate reflection on the importance of good written and verbal communication. In addition the Trust has considered its management of VTE and has set up a Task and Finish Group which is co-chaired by our Deputy Medical Director, , and our Director of Clinical Quality, . The Task and Finish Group will consider a number of areas including those which are referred to in your Regulation 28 Report and include:-
1. Undertaking a review of current UHL Guidance and measure it against NICE recommendations.
2. Undertaking a review of written discharge information provided to patients/relatives.
3. Undertaking a review of current thromboprophylaxis practice within the Trust and measure this as against NICE Guidance. This will include the provision of AES and accompanying advice. Cont'd ..... University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary. Website: www.leicestershospitals.nhs.uk
4. Identifying the training provided for thromboprophylaxis and any further training required.
5. Undertaking a governance review and oversight of VTE arrangements within the Trust and oversight of the Trust's Thrombosis Prevention Committee. This will include a review of information given to patients on discharge.
6. Overseeing the development of a Standard Operating Procedure for use between our Emergency Department and our fracture clinic. An interim report is expected to be available by the end of January 2019 and a final report is expected to be available by the end of March 2019. I would be happy to share these reports with you. Please let me know if you would like to see them. What further actions are taken thereafter undertaken will obviously depend on the findings of the Task and Finish Group. While this work is underway we have issued a VTE Learning Bulletin to all clinical staff reiterating the Trust's Guidelines for Pharmacological and Mechanical Thromboprophylaxis for VTE and the lessons learned from this death. Through this bulletin staff were reminded of the need to ensure that in all cases where a patient requires ongoing DVT prophylaxis post-operatively and post-discharge this is documented in the patient's notes, and recorded in the patient's prescription, and that this information includes details of how long the stockings need to be worn. Medical Staff were asked to ensure that this bulletin is discussed with their teams and cascaded to all relevant juniors. This work was led by our Deputy Medical Director, Colette Marshall. trust that this provides you with the assurance that we have taken this matter very seriously. If you would like any further information please do not hesitate to contact me.
1. Undertaking a review of current UHL Guidance and measure it against NICE recommendations.
2. Undertaking a review of written discharge information provided to patients/relatives.
3. Undertaking a review of current thromboprophylaxis practice within the Trust and measure this as against NICE Guidance. This will include the provision of AES and accompanying advice. Cont'd ..... University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary. Website: www.leicestershospitals.nhs.uk
4. Identifying the training provided for thromboprophylaxis and any further training required.
5. Undertaking a governance review and oversight of VTE arrangements within the Trust and oversight of the Trust's Thrombosis Prevention Committee. This will include a review of information given to patients on discharge.
6. Overseeing the development of a Standard Operating Procedure for use between our Emergency Department and our fracture clinic. An interim report is expected to be available by the end of January 2019 and a final report is expected to be available by the end of March 2019. I would be happy to share these reports with you. Please let me know if you would like to see them. What further actions are taken thereafter undertaken will obviously depend on the findings of the Task and Finish Group. While this work is underway we have issued a VTE Learning Bulletin to all clinical staff reiterating the Trust's Guidelines for Pharmacological and Mechanical Thromboprophylaxis for VTE and the lessons learned from this death. Through this bulletin staff were reminded of the need to ensure that in all cases where a patient requires ongoing DVT prophylaxis post-operatively and post-discharge this is documented in the patient's notes, and recorded in the patient's prescription, and that this information includes details of how long the stockings need to be worn. Medical Staff were asked to ensure that this bulletin is discussed with their teams and cascaded to all relevant juniors. This work was led by our Deputy Medical Director, Colette Marshall. trust that this provides you with the assurance that we have taken this matter very seriously. If you would like any further information please do not hesitate to contact me.