Non-inquest findings into the death of Lenore

Contributing factors

• No VTE risk assessment performed at any stage of admission despite multiple clear risk factors
• Failure to prescribe VTE prophylaxis
• Excessive workload on medical team (21 ward patients plus 6 ambulatory patients reviewed by single senior medical officer and intern)
• Lack of standardised VTE risk assessment tool across health service
• Minimal clinician education regarding VTE risk assessment, documentation and management
• Inadequate clinical documentation
• Variability in VTE assessment practice due to reliance on clinical judgement
• Multidisciplinary safety net hampered by pharmacy staffing models and care plan design
• Five missed opportunities for VTE risk assessment across two hospital admissions and transfers
• New rotation of medical interns requiring close supervision coinciding with high workload

Coroner's recommendations

1. Implement standardised VTE risk assessment tool across health service
2. Require individual VTE and bleeding risk assessments for all patients presenting to ED with lower limb injuries and all medical, surgical, mental health, rehabilitation, maternity and palliative care patients within 12 hours of admission
3. Link clinicians to interactive Queensland Health VTE risk assessment tool via single web page and Med App
4. Make clear the admitting medical officer's responsibility for prescribing thromboprophylaxis and documenting risk assessment outcome in patient flow system
5. Require nursing staff to discuss VTE risk and prophylaxis during clinical handover
6. Require daily monitoring of patients for signs and symptoms of DVT
7. Require medical officers to review pharmacological VTE prophylaxis daily
8. Require reassessment of VTE and bleeding risk regularly as clinically appropriate
9. Implement stickers on charts to highlight when VTE risk assessment has not been completed
10. Provide regular clinician education on VTE risk assessment, documentation and management
11. Review workload and staffing models to ensure adequate resources for thorough patient assessment
12. Improve care plan template design to make VTE prevention strategies more clearly identifiable