The Dudley Group NHS Trust
NHS / Health Body
Action Taken
Following the incident, it has been made clear to all staff that the Evergreen area is part of the Trust's services and subject to the VTE assessment policy. Awareness and the need for VTE assessments has been discussed with medical teams and will be raised again at the next mandatory Medicine Audit meeting. The Evergreen area is being reconfigured to re-designate the beds as acute. (AI summary)
View full response
Dear Mr Siddique, Regulation 28 report
— Mr Kenneth Evans The circumstances of this failure to implement our existing policy were unusual in that the patient had been due for discharge from the acute service and because of a series of repeated delays in his discharge plans he was subsequently transferred to an intermediate care area of the hospital supervised by primary care physicians
— Evergreen, and, therefore, had not been reassessed for VTE prophylaxis during this prolonged discharge journey. The Evergreen area is an intermediate care area where patients are admitted following discharge from the acute trust. These beds are utilised for patients who need nursing care but who are otherwise medically fit (analogous to nursing home patients). Following this incident we have made it clear to all staff that Evergreen is part of our services and thus subject to our Trust policy on VTE assessments. I have enclosed the Trusts policy for venous thromboprophylaxis (VTE) for your information as part of the Policy there is detail on how we monitor compliance with this Policy (contained within Appendix 1 of the Policy). Currently compliance in undertaking a VTE assessment for prophylaxis is at 93% for the Trust. All members of clinical staff are trained in the assessment of patients for VTE prophylaxis as part of their mandatory training.
Awareness & the need for VTE assessments has been discussed with our medical teams and following your letter to the Trust is timetabled to be raised again at the next mandatory Medicine Audit meeting with this specific case being presented to the multidisciplinary teams attending. On a further note due to the changing pattern & patient demand we are reconfiguring the Evergreen area to re-designate the beds as acute and these will be looked after by consultant medical staff. I hope that the above gives you confidence that whilst this failing was a result of a series of unusual events regarding Mr Evans discharge we have taken steps to remove any possible ambiguity in respect of undertaking a VTE assessment in accordance with our established and audited policy for all areas of the hospital.
— Mr Kenneth Evans The circumstances of this failure to implement our existing policy were unusual in that the patient had been due for discharge from the acute service and because of a series of repeated delays in his discharge plans he was subsequently transferred to an intermediate care area of the hospital supervised by primary care physicians
— Evergreen, and, therefore, had not been reassessed for VTE prophylaxis during this prolonged discharge journey. The Evergreen area is an intermediate care area where patients are admitted following discharge from the acute trust. These beds are utilised for patients who need nursing care but who are otherwise medically fit (analogous to nursing home patients). Following this incident we have made it clear to all staff that Evergreen is part of our services and thus subject to our Trust policy on VTE assessments. I have enclosed the Trusts policy for venous thromboprophylaxis (VTE) for your information as part of the Policy there is detail on how we monitor compliance with this Policy (contained within Appendix 1 of the Policy). Currently compliance in undertaking a VTE assessment for prophylaxis is at 93% for the Trust. All members of clinical staff are trained in the assessment of patients for VTE prophylaxis as part of their mandatory training.
Awareness & the need for VTE assessments has been discussed with our medical teams and following your letter to the Trust is timetabled to be raised again at the next mandatory Medicine Audit meeting with this specific case being presented to the multidisciplinary teams attending. On a further note due to the changing pattern & patient demand we are reconfiguring the Evergreen area to re-designate the beds as acute and these will be looked after by consultant medical staff. I hope that the above gives you confidence that whilst this failing was a result of a series of unusual events regarding Mr Evans discharge we have taken steps to remove any possible ambiguity in respect of undertaking a VTE assessment in accordance with our established and audited policy for all areas of the hospital.