Nicola Tweedy

Chief Operating Officer 

Richmond House  
79 Whitehall 
London 
SW1A 2NS 

Ms J Lake 
Senior Coroner 
Coroner’s Court 
69-75 Thorpe Road 
Norwich 
Norfolk 
NR1 1UA 

11 May 2015 

Dear Ms Lake  

Thank you for providing the Department with a copy of your Regulation 28 Report following 
the inquest into the death of Nicola Tweedy. I was very sorry to hear of Mrs Tweedy’s death 
and wish to extend my sincere condolences to her family. 

I  understand  that  you  found  that  Mrs  Tweedy  died  following  a  rare  but  recognised  risk  of 
surgery for varicose veins. You draw attention to several serious issues that arose during Mrs 
Tweedy’s stay in hospital which, if addressed, could prevent future deaths from occurring.  

I  note  that  you  have  sent  your  report  to  the  Norfolk  and  Norwich  University  Hospital  NHS 
Foundation Trust. My officials have liaised with the Foundation Trust about your report and I 
understand that it has fully considered and responded to each of your concerns relating to the 
care of Mrs Tweedy. I can report that a recent independent external inspection found that the 
Foundation  Trust  had  implemented  an  Action  Plan,  to  address  the  issues  raised  by  this  case, 
and that this demonstrated that learning and improvement had taken place.   

I  am  aware  that  you  sent  our  Department  a  copy  of  your  report  for  interest  and  were  not 
expecting a direct response. Nevertheless, I would like to take this opportunity to  respond to 
some of the issues that your report raises. I have sought views from officials at NHS England 
to enable me to do this. 

The Department is aware of the importance of reducing the risk of venous thromboembolism 
(VTE) in hospital patients and the need for all nurses and health care assistants to understand 
VTE prevention procedures, and the reasons for these procedures. This is why the Department 
recommends  use  of  a  risk  assessment  checklist  and  published  a  VTE  risk  assessment  tool  in 
2010: 

http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consu
m_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113355.pdf  

This  tool  helps  to  ensure  that  assessments  take  place  for  every  patient,  and  that  results  are 
closely monitored in order to reduce preventable deaths from VTE. 

In addition, The National Institute for Health and Care Excellence (NICE) published guidelines 
in 2010, Venous thromboembolism: reducing the risk. Clinical guideline 92, which offers best 

 
  
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 practice  advice  on  reducing  the  risk  of  VTE  in  patients  admitted  to  hospital.  The  guidelines 
recommend that all patients, including those admitted for day medical or surgical procedures 
should be individually assessed for risk of VTE and that the risks and benefits of prophylaxis 
should be discussed with the patient.  

VTE prevention has been recognised as a clinical priority for the NHS by the National Quality 
Board  and  the  NHS  Leadership  Team.  It  has  been  identified  as  the  most  important  patient 
safety practice in our hospitals, and VTE-specific indicators feature in both the NHS Outcomes 
Framework and the Clinical Commissioning Group Outcomes Indicator Set. 

NHS  commissioners  are  required  to  undertake  root  cause  analysis  of  all  cases  of  hospital-
acquired VTE, in line with the National CQUIN (Commissioning for Quality and Innovation) 
goal 2013/14, to enable commissioners to address gaps in service provision.  

There  are  a  number  of  levers  available  to  commissioners  to  ensure  that  their  providers’ 
maintain  patient  safety  practices  in  relation  to  VTE  prevention.  First  and  foremost,  local 
commissioners  should  make  certain  that  they  fully  utilise  the  provider  payment  incentives 
provided by the national VTE CQUIN Goal 2013/14. There are two indicators that must be met 
in order to qualify for a single provider payment:-  

1)  Proportion of all adult inpatients that have been assessed for risk of VTE on admission to 
hospital must be at least 95%. The commissioners can access quarterly data on the number and 
proportion of VTE risk assessments carried out by providers and can withhold payment if the 
threshold is not met; and 
2)    Root  cause  analysis  should  be  carried  out  on  all  cases  of  hospital-acquired  VTE.  The 
proportion of cases subject to root cause analysis necessary to trigger the CQUIN payment is to 
be determined locally. 

The  National  VTE  Prevention  Programme  (http://www.vteprevention-nhsengland.org.uk/) 
publishes  data,  from  NHS  England's  data  collection,  on  the  number  of  inpatients  admitted 
monthly that have been risk assessed for VTE on admission to hospital, using the criteria in the 
National VTE Risk Assessment Tool.  

Data  for  VTE  Risk  Assessment  Quarter  4,  2013/14  (January  to  March  2014)  (revised  July 
2014), shows that the Norfolk and Norwich University Hospitals NHS Foundation Trust, risk-
assessed 98.29% of admitted patients for VTE in March 2014.        

As a result of this case NHS England has agreed to look at the potential for national learning at 
the next meeting of the VTE Programme Board. NHS England has also been in direct contact 
with 
  to  reaffirm  its  commitment  to  doing  everything  it  can  to  prevent  hospital-
associated thrombosis, through the efforts of the National VTE Prevention Programme.  It will 
also update 

 as national initiatives progress. 

Lastly,  as  some  of  the  actions  of  medical  and  nursing  staff  are  subject  to  criticism  in  your 
report, I wish to take this opportunity to remind you of the role of the professional regulatory 
bodies and their fitness-to-practise processes.  

As  you  may  be  aware,  Doctors  must  register  with  the  General  Medical  Council  (GMC)  and 
Nurses  must  register  with  the  Nursing  and  Midwifery  Council  (NMC)  and  meet  set 
professional standards to work in the UK and be fit for practise. If an allegation is made about 
a  registrant,  who  may  not  meet  the  professional  standards  required  in  the  UK,  the  relevant 
regulatory  body  has  a  duty  to  investigate  and,  where  necessary,  take  action  to  safeguard  the 

 
 
 
 
 
 
 
 
 
 health and well-being of the public. The Department cannot get involved with or comment on 
individual cases.  

I  will  ensure  that  a  copy  of  your  report  and  our  response  is  sent  to  the  Care  Quality 
Commission.  

I hope that this response is helpful and I am grateful to you for bringing the circumstances of 
Mrs Tweedy’s death to my attention. 

Yours sincerely

14 MAY 206

Peps Toe ey ten Norfolk and Norwich University Hospitals NHS)
for those Wwe love the most NHS Foundation Trust

Trust Management Offices

Norfolk & Norwich University Hospitals

Ms Jacqueline Lake NHS ony tne

HM Coroner Norwich NR4 7UY

Norfolk Coroner's Office
69-75 Thorpe Road
Norwich NR1 1UA

Our Ref: ADMvri!Q. 14.022

11 May 2015

Dear Mrs Lake
Nicola TWEEDY (Deceased)

Further to my letter of 23 March, | attach a copy of our response to your Report arising from
the death of Mrs Tweedy. This is in table form, to ensure that we have addressed each of
the issues that you raised.

| anticipate that the response will be self-explanatory, although some of the issues
concerned are complex. If it would be helpful to discuss at all please let us know.

You will appreciate that the question of thromboprophylaxis following day case surgery is
contentious and the evidence base on which to found best practice is limited. | should
therefore make clear that the change in prescribing practice introduced by surgeons at our
Trust was based on our ongoing audit of 60,000 day case patients over the last 5 years,
tather than on the sad outcome in Mrs Tweedy’s individual case. Rare complications will
sometimes occur and there are genuine concerns that increased use of thromboprophylaxis
will generate increased risks of bleeding for other patients. We will continue to monitor the
position closely.

There are always opportunities to learn and, as you know, we produced an action plan in
advance of your Inquest in this case. Recent external inspection has confirmed that we had
implemented the actions we had identified in our plan and that this “demonstrated that
learning and improvement had taken place’.

On an administrative point, we understand that a copy of your report was also sent to the
Department of Health, but it contained a different date for our response to be received. In
order to avoid confusion, | can confirm that we have responded within the timeframe stated
in the original report that you sent to the Hospital.

Yours sincerely

CRief Executive

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