Inquest into the Death of frith

Contributing factors

• Delayed surgical fixation of femur fracture (deferred from 5 July to 6 July 2005)
• Increased immobility following fracture
• Discontinuation of aspirin (Solprin) prior to surgery, removing chemical DVT prophylaxis
• Uncertainty regarding application of TED stockings prior to operation
• Unclear placement of TED stocking prescription on medication chart rather than nursing care plan
• No documented confirmation of mechanical prophylaxis being applied or checked
• Theatre operating list overrun causing delay in scheduled surgery

Coroner's recommendations

1. A decision should be made as to the appropriate place in a patient's medical file for an instruction from a physician regarding application of TED stockings in the absence of agreement they be automatically applied
2. The instruction for TED stockings should be noted accordingly on a relevant chart or plan which provides space for nursing staff to record the fact of placement and continued compliance
3. The correct place for TED stocking instructions and the correct chart/plan should be communicated by way of protocols in each hospital/ward
4. Appropriate places for TED stocking instructions include observation charts, the usual nursing care plan, or progress notes, with the nursing care plan or observation chart having the advantage of providing space to ensure observations regarding replacement if removed
5. Each ward needs to agree upon its protocols for instruction to nurses for the placement of TED stockings