the course of the Inquest the evidence revealed matters giving rise to concerns: In my opinion there is risk that future deaths will occur unless action is taken: In circumstances it is my statutory to make this report to you appreciate there has been an RCA Investigation and an Action Plan. was provided with an updated copy of the Action Pian and it is reassuring to note that several measures have been undertaken to reduce the risk of a similar incident occurring in future_ note that the RCA Report states that the Root Cause was 'Omission to prescribe chemical or mechanical VTE prophylaxis because of technical difficulties with EPR_ This omission was not resolved at a later date. The report goes on to say this incident is classified as an avoidable VTE event and that this is therefore an avoidable death by definition and that the failure to provide any prophylaxis meant that the risk of a fatal PE must have been increased. heard evidence about a number of checks and fail-safe procedures refer to two in particular: The first concerned the training, experience and knowledge of nursing staff on the trauma wards who are very familiar with the requirements for VTE prophylaxis and a tendency for the nurses to pick up and deal with any omissions in this regard: The second check is the EPR alerts The first concern relates to what are referred to as 'outlying patients' Mrs Grant went the emergency department to neuro-science ward because there were no beds on trauma ward_ It appears that her placement on a ward other than a trauma ward raised issues in respect of her care and, in particular, it meant she was not being cared for by trauma nurses who might ordinarily be expected to pick up the omission concerning VTE prophylaxis_ understand it is relatively common for a trauma patient to be placed on a ward other than a trauma ward, understand that this may be unavoidable but am concerned about there sufficient safeguards in place. see the Action Plan that recommendations and refer to this issue_ There has been an audit and the trauma co-ordinator is to check VTE prophylaxis has been prescribed to trauma patients outlying on non-trauma wards. seek reassurance that the audit of care for such patients confirms that the same standard of care is delivered regardless of location. also seek information and reassurance about the practical steps taken by the trauma co-ordinator to check VTE prophylaxis: There were a number of system checks which failed in this case and it is therefore important that system checks are effective_ legs During the duty from being from The second concern relates to ignoring the VTE prophylaxis alerts on EPR. note from the RCA Report that the warning was visible on exiting the record by all staff_ explained however that often the warning would not be seen because sometimes a doctor does not actually exit the record but keeps it open (albeit secure). It is surprising that from the time of transfer to the neuro-science ward from ED until the_time when the patient was seen by the Consultant Anaesthetist) on the morning of surgery on 16 April that the EPR was accessed 27 times by staff members and yet none of the staff interviewed recalled seeing the alert: system designed with fail-safes in the form of alerts is obviously not effective if the alerts are not seen or routinely ignored. Recommendation 8 on the Action Plan refers to this issue and see that an email has been sent out to the EPR Lead and that a new version of EPR will prevent staff able to exit the EPR record until VTE alerts have been dealt with_ As mentioned, it seems though that doctors do not always exit the record and, as understand it; the alert will not pop up unless the record is exited, It would be appreciated if you could provide some clarification on this and also address the wider issue of alerts not acted upon_