Francoise Snape
PFD Report
Historic (No Identified Response)
Ref: 2015-0054
Coroner's Concerns (AI summary)
No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE guidelines regarding DVT prevention and mechanical anti-DVT devices, representing a lost opportunity for care.
View full coroner's concerns
the course of the inquest the evidence revealed mv opinion there is a risk that future deaths will matters giving rise to concern. In circumstances it is my statutory duty to occur unless action is taken. In the report to you: , (1)No VTEassessment was ever made of Mrs Snape. was that staff were too The explanation given byE She had had a stroke heparin busy to complete the form and that because unnecessary: could not be given and therefore the paperwork was (2) NICE guidelines regarding the use of mechanical anti DVT heparin inhigh risk cases was not consideredt devices instead of indicated in his being artery During eerderice that I{he guidance on such malters was to be found in regarding DVTs and not in "stroke" guidance The clear 'general" guidance not aware of the content of the difference was that he was to as involving stroke patients general guidance despite it being specifically referred anaaclear in the Inquest that the absence of a formally = and lack of knowledge of NICE guidelines completed VTE assessment informed decisions for the care of Mrs amounted to a lost opportunity to make changed the outcome for her. Snape which may (but only may) have (3)
Sent To
- Worcestershire Acute Hospitals NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
10 Apr 2015
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 14th August 2014 commenced an Annabel SNAPE then aged 59. investigation into the death of Francoise Simone The investigation concluded at the end of the inquest on 11th February The conclusion of the inquest was she died as tneeesont 2015_ necessary medical treatment the medical of a known complication of haemorrhage Ib) massive cause of death la) left intracerebral territory infarction pulmonary embolus (thrombolysed) Ic) left midceeerebral
Circumstances of the Death
On the 20d August 2014 Mrs Snape was admitted into following an infarcted stroke Worcestershire Royal Hospital Shienoas managed conservatively until 11" August when she pulmonary embolus developed massive herdeaoembolitic medication was given which caused a catastrophic bleed resulting in
Action Should Be Taken
bome opinion action should be laken to prevent future deaths power to take such action ie. a) to ensure that and believe you have the is made in all appropriate a full proper and formal VTE assessment cases and that paperwork is always fully and completed, b) to ensure that all staff (and particularly clinical properly relevant guidelines issued by NICE or other leads) are aware of all contained within agencies no matter which document it is
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.