Vauna Leeming
PFD Report
All Responded
Ref: 2025-0033
All 1 response received
· Deadline: 14 Mar 2025
Response Status
Responses
1 of 1
56-Day Deadline
14 Mar 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1) Following Mrs. Leeming’s surgery on 8.2.24, measures were put in place to prevent the formation of a deep vein thrombosis and/or pulmonary embolism. Those measures were prescriptions for anticoagulation medication ( Enoxaparin ) and for compression stockings. The inquest heard evidence that over the 46 days between the surgery and Mrs. Leeming’s death: (a) on 2 days ( 10 and 13.2.24 ) no documentation was completed by nurses to show whether Enoxaparin had in fact been administered; and (b) on a total of 15 days ( including 5 consecutive days in one week ) no documentation was completed by nurses to show whether compression stockings had been fitted and were being worn;
2) It was of particular concern that for 5 consecutive days, no nurse had noticed or raised with a senior colleague that the prescription charts had not been completed to show that compression stockings had been fitted. This suggests either that there is little understanding of a nurse’s professional duty to report such omissions, or that the practice of not checking and completing such important documentation is commonplace;
3) The inquest heard evidence that whilst in its induction to new nurse employees, the Trust emphasises the importance of completing documentation, it is still heavily reliant on agency nurses, for whom it cannot be expected to provide such an induction;
4) I am concerned that the evidence in this case highlights that there is still insufficient awareness among employed and agency nurses at the Trust’s hospitals 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.
2) It was of particular concern that for 5 consecutive days, no nurse had noticed or raised with a senior colleague that the prescription charts had not been completed to show that compression stockings had been fitted. This suggests either that there is little understanding of a nurse’s professional duty to report such omissions, or that the practice of not checking and completing such important documentation is commonplace;
3) The inquest heard evidence that whilst in its induction to new nurse employees, the Trust emphasises the importance of completing documentation, it is still heavily reliant on agency nurses, for whom it cannot be expected to provide such an induction;
4) I am concerned that the evidence in this case highlights that there is still insufficient awareness among employed and agency nurses at the Trust’s hospitals 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.
Responses
Worcestershire Acute Hospitals NHS Trust held an Extra-Ordinary VTE meeting and increased VTE compliance monitoring. Ward managers are reinforcing the duty for staff to sign prescription charts, and the Trust plans to update/re-circulate a lesson of the week, request electronic prescribing chart improvements, undertake regular audits, and provide monthly compliance reports.
AI summary
View full response
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
Tel:
Fax:
Email:
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.
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
Tel:
Fax:
Email:
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.
Report Sections
Investigation and Inquest
On 3 April 2024 I commenced an investigation and opened an inquest into the death of Vauna LEEMING. The investigation concluded at the end of the inquest on 15 January 2025.
The conclusion of the inquest was that Mrs. Leeming “died from natural causes, to which a recent fractured neck of femur and surgical repair thereof contributed”.
The conclusion of the inquest was that Mrs. Leeming “died from natural causes, to which a recent fractured neck of femur and surgical repair thereof contributed”.
Circumstances of the Death
In answer to the questions “when, where and how did Mrs. Leeming come by her death?”, I recorded as follows:
“On 6.2.24 Vauna Leeming was admitted to Worcestershire Royal Hospital after suffering an accidental fall at home, and was found to have sustained a fractured right neck of femur. She underwent surgery to repair the fracture on 8.2.24, from which she initially made a satisfactory recovery. However, on 23.3.24 her condition deteriorated, and she tested positive for Covid-19. She went on to suffer a pulmonary embolism and, despite treatment, declined and died in hospital on 25.3.24.”
“On 6.2.24 Vauna Leeming was admitted to Worcestershire Royal Hospital after suffering an accidental fall at home, and was found to have sustained a fractured right neck of femur. She underwent surgery to repair the fracture on 8.2.24, from which she initially made a satisfactory recovery. However, on 23.3.24 her condition deteriorated, and she tested positive for Covid-19. She went on to suffer a pulmonary embolism and, despite treatment, declined and died in hospital on 25.3.24.”
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.