Dear Ms Andrews Inquest into the death of Ann Dorothy Pearce Thank you for your letter of 28 November 2023, enclosing your formal report under Regulation 28 to Prevent Future Deaths. My heartfelt sympathy and condolences to Mrs Pearce's family. We have taken considerable actions and made extensive improvements to patient safety following Mrs Pearce's death and the inquest, and I will set these out below. We have developed a Trust policy for Thromboprophylaxis in Ambulatory Trauma Patients discharged from the Emergency Department. In addition, patient advice leaflets have been designed for clinicians to give to patients. The patient advice leaflets are as follows: Immobilisation advice leaflet Anticoagulation treatment with Dalteparin Anticoagulation treatment with Enoxaparin A Trust Theme of the Week message has been sent to all staff on 'VTE in lower limb injury and immobilisation' to ensure our clinical teams are up to date and this includes the top 3 'need to know' points as follows:
1. All patients will need baseline bloods (FBC, U&Es, LFTs and coagulation profile) within the last three months to aid prescribing of thromboprophylaxis.

2. If there are no contraindications, patients will need to be prescribed and discharged with 30 days of LMHW, or rivaroxaban if LMWH is contraindicated; if suspected Achilles tendon rupture then a 42 day course should be prescribed.
3. All patients will need advice leaflets on reducing the risk of VTE with lower limb immobilisation and anticoagulation treatment with Dalteparin or enoxaparin, or rivaroxaban. The key learning, patient leaflets, and new policy are being widely shared and discussed in department, team, and divisional safety huddles and meetings. Mrs Pearce's case has had an immense impact throughout the Trust and the learning has been disseminated widely as her legacy to improve patient safety. Once again, my sincere condolences to Mrs Pearce's family. I hope you are assured by the changes we have made.