“The first concern relates to what are referred to as ‘outlying patients’”

The coroner’s concerns

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1. The first concern relates to what are referred to as ‘outlying patients’. Mrs Grant went from the emergency department to a neuro-science ward because there were no beds on a trauma ward. |t 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 ona ward other than a trauma ward. | understand that this may be unavoidable but | am concerned about there being sufficient safeguards in place. | see from the Action Plan that recommendations 1 and 7 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. 2. 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. MM 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 I 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. A 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 being 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 being exited. It would be appreciated if you could provide some clarification on this and also address the wider issue of alerts not being acted upon.

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judiciary.uk, Prevention of Future Deaths reports

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0