Dear Ms Mundy Re: Gordon Frank THORNHILL (Deceased) write in response to the Regulation 28 Report "Prevention of Future Deaths" dated 4 December 2017 sent to the Chief Executive of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust and for which thank you: note your concerns as follows; Junior doctors failure to complete the mandatory VTE risk assessment 2 The Consultants VTE assessment done the day following admission failed to identify incomplete/failure to complete VTE risk assessment 3 The Consultant carried out his own assessment as "mental exercise" and did not document his assessment in excess of 24 hours in providing thromboprophylaxis would respond as follows;
1. The Trust has policy entitled Venous Thromboembolysm (VTE) Prevention and Treatment of VTE in Patients Admitted to Hospital: This policy is available on the intranet and has been in place since July
2014. It is currently reviewed to take into delay being

consideration the changes within the organisation but the essence of the prevention policy will remain intact_ The policy clearly identifies the role that individuals have in assessing and ensuring that patients receive the appropriate prophylaxis. enclose a copy of the policy: am advised by the Director of Education that VTE prophylaxis is addressed at induction and there is an electronic package approved by Health Education England which trainees have to complete for their annual review (ARCP) This is monitored through the post graduate schools on behalf of Health Education England. This should be supplemented by on-site support and monitoring by consultants. In light of the events that you highlight have personally written to all consultants and associate specialists advising them of the importance of ensuring that VTE assessments are completed and documented on the post- take ward round and to that end to provide the required support for trainees:
3. am advised by the VTE Lead for the Trust that the junior staff also receive reminders with respect to completing the assessments and prescribing the appropriate prophylaxis:
4. The Trust has system of medicines reconciliation for acute admissions on the medical assessment unit and the pharmacists are actively involved in ensuring that this process runs smoothly and also highlighting whether prophylaxis has been prescribed. On this occasion the prophylaxis was prescribed but due to human error it was prescribed to commence on the following day: The message of timely prescription has been reinforced_
5. am advised by the VTE Lead for the Trust that there is currently quality improvement project undertaken on the medical assessment unit to ensure greater compliance with the medical VTE risk assessment form and to ensure that this is reviewed on the post-take ward round and where appropriate prophylaxis is actually prescribed and given in timely manner.
6. Finally the Trust is in the process of re-launching the "Stop the Clot" campaign which was successful in the early years in ensuring VTE prophylaxis was appropriately undertaken and in timely manner. This will include strategically placed posters in ward areas and the education centre as well as use of the Trust'$ communication systems (Buzz, Risky Business) to highlight the importance of risk assessment and prescription of prophylaxis. The same message will be on the Intranet trust that the contents of this letter will reassure you that the Trust takes VTE prophylaxis most seriously and that processes are in place to ensure that doctors have the appropriate competence and understanding to assess and prescribe prophylaxis where appropriate_ Please do not hesitate to revert back to me should you feel that there are still any outstanding issues Yours sincerell Mr R: J. Cuschieri MD. ChM: MEd FRCS Deputy Medical Director Clinical Standards being

Enc: Trust VTE Policy Cc