Dear Mrs Whitting Re: Robert Dymond write in response to your Regulation 28 Report to Prevent Future Deaths issued on July 2017_ The Trust's Haematology Department devise and manage the Trust's pathway for the management of the DVTs and would have been pleased to have been given the opportunity of providing you with evidence on this matter at the Inquest. In order to address your concerns their advice has been obtained. As you have stated the NICE guidance refers to the commission of proximal scans, which are taken at the knee level and show the veins at that point. When a proximal scan is undertaken they advise that repeat scan should be undertaken 6-8 days later when there is positive D Dimer and negative proximal scan_ The reason that this practice is not adopted by the Trust is because at UHCW, we undertake a more extended scan as routine which shows the leg veins below the knee to the trifurcation in the calf. This is discussed in NICE guideline 144 section 4.1 which states that whole leg scans do not routinely need a repeat scan: Therefore we believe that the Trust's pathway goes beyond the minimum requirements and accordingly we experience very low numbers of venous thromboembolism following discharge from the DVT service: Further; the Trust's standard practice in patients with a high risk Wells score and raised D-Dimers is to contact the patient 5-7 days later and arrange a repeat scan if the symptoms are not settling: Only small proportion of patients who present with isolated distal DVTs extend to the proximal veins Those that do not extend, rarely lead to clinically significant emboli as recognised by the British Society of Haematology national guidelines, a copy of which is attached by way of information. Chief Executive Officer: Andrew Hardy Chairman: Andrew Meehan 25th

The NICE rationale for repeating a scan is to detect those distal clots which have extended into the proximal veins as in this situation the symptoms will not resolve and would be anticipated to worsen. Therefore, for that reason patients whose symptoms are resolving are not recommended to have a repeat scan: It is also of note that the Trust use high sensitivity D Dimer kit and the British Society of Haematologists guidance states that patients with a moderate risk Wells score (1-2) can follow the of low probability if such a test is used: The haematologists do consider it unlikely that the patient did have proximal DVT as he was untreated and does not appear to have had any further problems up until his surgery 4 months later. As no DVT was identified by the investigations it would not have been relevant to pre-operative assessment and would not have been relevant to the operating team_ We hope this gives assurance that appropriate actions are in place for the management of DVT's Yours sincefely Professor Andrew Hardy Chief Executive Officer Chief Executive Officer: Andrew Hardy Chairman: Andrew Meehan leg very path the