13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
14. Mr F has concerns that his wife was at risk of thrombosis (a blood clot), so was started on anticoagulant medication in hospital, but was then discharged without this in place. He says her mobility had decreased and it was identified she needed the medication. He says if this was indicated in hospital, this was needed at home. Her mobility was poor at home, and she was at greater risk on discharge than when she arrived. He has concerns that if his wife had been continued on and discharged with an anticoagulant, her death would have been avoided.
15. The Trust says Mrs F was identified as a risk of DVT during her admission and prescribed a low molecular weight heparin (a class of medication used as an anticoagulant) to prevent this.
16. The Trust says Mrs F was not at any increased risk of VTE compared to most other patients who have reduced mobility in the hospital. It says patients on prophylactic enoxaparin are not sent home on this medication unless there is a guideline based clinical indication for it. It says this was not the case for Mrs F who was on standard prophylactic enoxaparin therapy which is common for patients who have reduced mobility whilst in hospital.
17. The thromboembolism guidance says all patients should be assessed in hospital to identify the risk of VTE and bleeding.
18. Mrs F went into hospital with influenza (flu), a respiratory illness. She was assessed on admission for her VTE risk. The risk assessment showed she was at an increased risk and needed treatment. This risk assessment was appropriate, and in line with the thromboembolism guidance.
19. Mrs F was then treated with pharmacological prophylaxis, which is a drug treatment. The guidance sets out the drugs which are indicated. Mrs F was prescribed enoxaparin (a form of low molecular weight heparin).
20. The thromboembolism BNF also says: ‘the choice of prophylaxis will depend on the medical condition, suitability for the patient, and local policy. Acutely ill medical patients who are at high risk of VTE should be offered pharmacological prophylaxis. Patients should be given either a low molecular weight heparin as a first-line option, or fondaparinux sodium as an alternative, for a minimum of 7 days. Patients with renal impairment should be given either a low molecular weight heparin or heparin (unfractionated) and the dose should be adjusted as necessary’.
21. Based on the above, we can see Mrs F was given the appropriate treatment in line with guidance. The guidance then prompts to consider mobilisation and hydration. Mrs F was prescribed fluids on admission, and it was considered that her mobility was reduced. Our adviser explains it is important to consider immobility as a contributing risk factor for DVT/PE, but this alone isn’t an indication for treatment. The Trust addressed Mrs F’s mobilisation and hydration in accordance with the guidance.
22. Being in hospital is a risk factor for DVT and PE is because a patient is in hospital with an illness. In this case, the risk factor and reason Mrs F needed an anticoagulant medication was due to her acute illness (influenza).
23. The thromboembolism guidance sets out prophylaxis should continue throughout a patient’s admission or a minimum of seven days. Mrs F’s admission spanned longer than seven days, and she received the medication up until the day before she was discharged. Our adviser explains this was the appropriate amount of treatment that is set out in the guidance, and there was no clinical indication she needed to be discharged with the medication.
24. As set out above, the reason Mrs F needed the medication was due to the risks of her acute illness whilst she was in hospital (influenza), combined with that she was over 60. Her acute illness had sufficiently resolved by discharge, and there was no clinical suspicion of DVT on discharge. The Trust’s management of Mrs F’s VTE risk was in line with the thromboembolism guidance. There was no indication to continue prophylactic treatment after discharge.
25. We recognise Mrs F suffered a DVT and very sadly died around four weeks later. We can understand why Mr F has serious concerns this could have been avoided with anticoagulant medication. Mrs F’s clinician presentation at the time of discharge was such that anticoagulant medication was not indicated. We hope this can provide him with some reassurance that the Trust acted in line with guidance.
26. We hope we have clearly explained the reasons for our decision and would like to reiterate our thanks to Mr F for taking the time to share his complaint with us.