Ellen Mercer

Frimley Park Hospital 
Portsmouth Road 
Frimley 
Camberley 
GU16 7UJ 

www.fhft.nhs.uk 

Senior Coroner for Berkshire, Heidi Connor 
Reading Coroner’s Court 

18 June 2024 

Dear Mrs Connor 

I write in response to the Regulation 28 Report you issued on 26 April 2024, following the 
inquest into the death of Ellen Mercer, which concluded on 10 April 2024. 

Your concerns were as follows: 

1.  Patients are unfortunately waiting increasingly longer times in emergency 

departments – not just in waiting areas, but also after being seen by clinical staff and 
waiting for admission to a ward or discharge from the hospital. During this time, 
current policies do not require VTE risk assessment. 

2.  The policy for this trust suggests that the 24 hour period (during which VTE risk 

assessment must take place) starts only when a patient is “admitted” to hospital, i.e. 
when a decision is taken to admit them to a ward – which could be many hours after 
they have originally attended the emergency department. 

3.  The policy as currently drafted implies that VTE risk assessment is essentially not 

relevant for emergency department patients. 

4.  If current policies require VTE risk assessment to take place within 24 hours, the 
point at which that 24 hour period starts is not sufficiently clear and does not take 
long waits in emergency departments into account. I am concerned that policies may 
need to reflect the current reality on the ground. 

5.  I suspect that this issue may be a national one. 

In partnership with the Ministry of Defence 

Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park Hospital 

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 Meeting on 22 May 2024 

On 22 May 2024 the Trust convened a meeting for key clinicians, clinical governance and 

legal colleagues to discuss the concerns raised in the Report and to consider how best to 

mitigate against the venous thromboembolism (‘VTE’) risk to patients in the Emergency 

Department (the ‘ED’) at Wexham Park and Frimley Park Hospital. The following colleagues 

were in attendance and contributed to the discussion: 

o 

o 

o 

o 

o 

o 

o 

o 

o 

 Consultant in Haematology; 

, Consultant in Haematology; 

, Head of Quality and Clinical Effectiveness; 

, Head of Legal Services; 

, Chief Medical Officer; 

, Consultant in Emergency Medicine and Chief of Service 

Emergency Medicine; 

, Deputy Legal Services Manager for Wexham Park; 

, Deputy Medical Director; and 

, Consultant Respiratory Physician and Chief of Service for 

Transformation and Continuous Improvement. 

During the meeting the clinicians considered the concerns as detailed in your Report to 

Prevent Future Deaths, the Trust’s VTE Policy and the NICE guidance titled: ‘Venous 

thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or 

pulmonary embolism [NG89] Updated 13 August 2019’ (the ‘NICE Guidance’). 

As was explained by 

 at the Inquest hearing, the Trust’s approach to VTE 

risk assessment has been informed by the NICE Guidance. However, the clinicians agreed 

that owing to unprecedented demand on services there are now patients waiting for far 

longer in ED than was perhaps contemplated when the NICE Guidance was drafted (which 

requires at paragraph 1.1.2 that medical patients should be assessed for risk of VTE and 

bleeding as soon as possible after admission or at the time of the first Consultant review), as 

was recognised at Ms Mercer’s inquest. 

Prior to the meeting, 

 had made enquiries of colleagues at a neighbouring Trust to 

understand their working practices in relation to VTE risk assessment and shared her 

In partnership with the Ministry of Defence 

Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park Hospital 

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 findings by way of email. I understand a neighbouring Trust has opted to depart from the 

NICE Guidance and has instead moved to ensuring VTE risk assessments are completed for 

patients in the ED who have been present for 12 hours or more. It is understood that their 

electronic patient record keeping system prompts clinicians to action the VTE assessment at 

the relevant time and a safety dashboard system is used to highlight patients requiring 

particular care interventions including VTE risk assessments. 

At the meeting the clinicians agreed in principle that patients attending the ED who have 

been present (for whatever reason) for 12 hours or more should be subject to a VTE risk 

assessment. It was  acknowledged that the finer detail of the Trust’s revised policy would 

need careful consideration and all were particularly mindful of the impact of adding to 

workloads of ED staff in the absence of additional resource. 

Trust’s Proposals 

The Trust is taking the concerns raised seriously and is committed to updating its VTE Policy 

so that VTE risk assessments are completed for patients who have been in ED for periods 

greater than 12 hours from arrival. It is recognised that the VTE Policy will also need to be 

revised to cover timescales for administration of any pharmacological VTE prophylaxis to be 

given to patients as appropriate (to reflect paragraph 1.1.4 of the NICE Guidance which 

states this should be given as soon as possible and within 14 hours of admission unless 

otherwise stated in recommendations). 

It is envisaged the following steps will be needed to effect the necessary changes: 

•  Consideration as to whether there may be patients who attend the ED for whom VTE 

risk assessments are not required and if so, how those patients can be screened out 

by using specific exclusion criteria. 

•  Consideration of who/ which speciality will complete the VTE risk assessment once 

the 12 hour mark has been reached, as required; 

o 

It is envisaged that where the patient has been referred on by ED, the 

speciality in receipt of the referral will be responsible for completing the 

assessment at the relevant time. 

•  Updates to the wording of Section 2 of the Trust’s VTE Policy; 

In partnership with the Ministry of Defence 

Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park Hospital 

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 •  Work with the Electronic Patient Record team to make 

changes to the Trust’s electronic record keeping system, EPIC, so that a prompt is 

generated at the relevant time; and 

•  Trust wide communication to be circulated by email explaining the changes to the 

policy, the Epic prompt and the rationale for the same. 

In due course the Trust will also need to update the Data Quality Improvement Plan in order 

to assess the effectiveness of the changes and inform consideration as to whether any 

further steps are needed to ensure the revised practice is embedded successfully across the 

Trust. The committees that will oversee progress will primarily be the VTE committee who 

meet every other month and also report into Patient Safety Steering Group (PSSG) 

quarterly. Care Governance Committee and quality assurance committees have oversight of 

the VTE committee’s work and PSSG’s reviews of VTE performance. 

Route to change 

In order to progress the above steps, the Trust has assembled a working group who will 

have responsibility for the amendments to the policy and the plan for rollout. The intention is 

for the group to meet fortnightly and for a representative to feedback to the afore mentioned 

VTE committees as to the group’s progress. 

The Trust intends to complete the necessary steps as described above within 12 weeks (by 

12 September 2024). 

I do hope the above provides sufficient reassurance as to the Trust’s ongoing commitment to 

patient safety and continuous service improvement. Please do let me know if any further 

information would be of assistance. 

Yours sincerely 

Chief Executive 

In partnership with the Ministry of Defence 

Frimley Health incorporates Frimley Park Hospital, Heatherwood Hospital and Wexham Park Hospital 

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Heidi J Connor 
Berkshire Coroner’s Office 
Reading Town Hall 
Blagrave Street 
Reading 
RG1 1QH 

National Medical Director 
NHS England 
Wellington House 
133-155 Waterloo Road 
London 
SE1 8UG 

17 June 2024 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Ellen Mercer who died on 
10 February 2023. 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26 April 
2024  concerning  the  death  of  Ellen  Mercer  on  10  February  2023.  In  advance  of 
responding to the specific concerns raised in your report, I would like to express my 
deep condolences to Ellen’s family and loved ones. NHS England are keen to assure 
the  family  and  the  coroner  that  the  concerns  raised  about  Ellen’s  care  have  been 
listened to and reflected upon. 

Your  report  raises  concerns  around  increasing  wait  times  within  Emergency 
Departments  (EDs)  and  the  delays  that  that  this  can  cause  to  patients  undergoing 
venous  thromboembolism  (VTE)  risk  assessments  while  they  await  admission  to  a 
ward, and that the current policies do not take long waits in emergency departments 
into account. 

NHS  England  recognises  the  pressures  that  continue  to  be  placed  on  Urgent  & 
Emergency Care (UEC) services. In January 2023, we published the Delivery Plan for 
recovering urgent and emergency care services which set out our plans and ambitions 
to improve the service over the next two years. The plan commits to improvements in 
five key areas: 

Increasing UEC capacity 
Increasing workforce size and flexibility 
Improving discharge 

• 
• 
• 
•  Expanding care outside of hospital 
•  Making it easier to access the right care. 

This includes patients being seen more quickly in emergency departments. An update 
on  the  plan,  published  in  October  2023,  noted  that  significant  progress  had  been 
made, despite pressures on the service remaining high. 

The National Institute for Health and Care Excellence (NICE), who I note you have 
also  addressed  your  Report  to,  are  responsible  for  the  relevant  clinical  guidelines 
[NG89] for VTE risk assessment. 

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 The  guidelines  currently  state  that  patients  should  be  risk  assessed  as  soon  as 
possible after admission, with admission defined as ‘Admission in the context of this 
guideline refers to admission as an inpatient, where a bed is provided for 1 or more 
nights,  or  admission  as  a  day  patient,  where  a  bed  is  provided  for  a  procedure 
including surgery or chemotherapy but not for an overnight stay’. 

Following a period of consultation, the VTE risk assessment data collection restarted 
as  of  1st  April  2024.  NHS  England’s  VTE  Risk  Assessment  Guidance  has  been 
updated with the following: 
‘To  support  the  collection  of  data,  NHS  England  has  clarified  that  risk  assessment 
should be completed on inpatients within 14hrs of admission; NICE guidelines state 
that  where  required,  pharmacological  thromboprophylaxis  should  be  started  within 
14hrs  of  admission,  therefore  risk  assessment  should  be  completed  prior  to  this, 
unless otherwise stated in the population-specific recommendations.’ 

We  do  not  think  it  is  likely  to  be  effective  to  require  ED  staff,  who  are  already 
experiencing  issues  with  their  capacity,  to  undertake  a  specific  risk  assessment  for 
VTE. This is supported by the Royal College of Emergency Medicine (RCEM), who 
we  note  in  their  response  to  you,  have  stated  that  ‘it  is  not  the  role  of  emergency 
medicine  doctors  to  be  undertaking  risk  assessments  that  specifically  relate  to  the 
hospital admission process’ and that this is the ‘role of the admitting specialty doctors, 
even when a patient is still in the ED’. The RCEM has issued clinical guidance on the 
clinical responsibility for patients who are located in the ED but who have been seen 
and  are  under  the  clinical  care  of  another  team.  The  guidance  states  that  ‘Once  a 
patient  in  the  ED  is  seen  by  a  specialty  team,  then  the  patient  becomes  the 
responsibility  of  the  speciality  team’.  UEC  colleagues  at  NHS  England  have  also 
advised that they would view the admission process to start once a decision has been 
made  to  admit  a  patient  and  that  an  assessment  for  VTE  should  then  be  made, 
including if the patient remains in the ED. 

However,  to  further  clarify  this  issue  and  acknowledging  that  there  is  an  ongoing 
heightened  demand  in  EDs  leading  to  significant  waits,  NHS  England’s  national 
Patient Safety Team have been in touch with NICE to suggest that their guidance is 
updated to reflect that VTE assessments should be undertaken within 14 hours of a 
‘decision to admit’, as opposed to admission. NICE have advised that they will be 
addressing the issue with their Prioritisation Board. 

I would also like to provide further assurances on national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 
other clinical and quality colleagues from across the regions. This ensures that key 
learnings and insights around preventable deaths are shared across the NHS at both 
a national and regional level and helps us pay close attention to any emerging trends 
that may require further review and action. 

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 Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director 

15

2nd Floor 
2 Redmond Place 
London 
E20 1JQ 
United Kingdom 

13 June 2024 

Mrs Heidi Connor 
Senior Coroner for Berkshire 
Berkshire Coroner’s Office 
Reading Museum and Town Hall 
Blagrave Street 
Reading 
RG1 1QH 

Dear Mrs Connor, 

I write in response to your regulation 28 report, dated 26 April 2024, regarding the very sad death of 
Ms Ellen Mercer. I would like to express my sincere condolences to Ellen’s family. 

We have reflected on the circumstances surrounding Ellen’s death and the concerns raised in your 
report, specifically that policies do not require assessment of VTE risk in people presenting at the 
emergency department. 

In terms of our guidance, we have published a guideline on venous thromboembolism in over 16s: 
reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism [NG89]. The 
guideline makes recommendations for VTE risk assessment for people admitted to hospital and we 
recommend assessing all medical patients to identify the risk of VTE and bleeding as soon as 
possible after admission to hospital or by the time of the first consultant review (recommendation 
1.1.2). 

The scope of the guideline does not cover people in the emergency department prior to admission. 
We have therefore not made any recommendations that cover the circumstances described in your 
report. 

We have recently implemented an organisation-wide approach to prioritisation and topic selection. 
This is overseen by a single prioritisation board that guides the selection and coordination of our 
guidance development. We will ask our prioritisation board to consider if guidance should be 
developed in this area. 

Please do let me know if you require any further information and again, I offer my sincerest 
condolences to Ellen’s family. 

Yours sincerely, 

Chief Executive 

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Mrs Heidi J Connor 
Senior Coroner for Berkshire 

21 May 2024 

Dear Mrs Connor 

Re: Report to Prevent Future Deaths E Mercer 26.04.2024 

Further to your prevention of Future Deaths Notice following the conclusion of your inquest (10.04.2024) 
into the death of Ellen Mercer who died on 10th February 2023, we would like to extend our sympathy 
and condolences to the family and friends of Ms Mercer. 

We  note  this  unfortunate  incident  occurred  in  the  setting  of  a  prolonged  stay  in  an  emergency 
department  (ED).  As  a  medical  royal  college  we  have  been  raising  concerns  nationally  for  a 
considerable period of time regarding the adverse consequences of prolonged ED length of stay / ED 
Crowding.  Our own publication highlights the consequences of ED crowding and its negative impact 
on  adverse  events,  prolonged  hospital  stays,  and  increased  mortality  and  morbidity  [1].  Delays  in 
assessment  and  diagnosis  are  features  of  crowded  emergency  departments;  the  Health  Services 
Investigation Body (HSSIB) have published a series of reports which also highlights the impact of these 
same factors in patient safety incidents [2]. 

We note from your Regulation 28: Report to Prevent Future Deaths notice that you identify the delay in 
a  risk  assessment  for  the  prevention  (as  opposed  to  treatment)  of  venous  thromboembolism  (VTE) 
being a concern and that the timing of the risk assessment may be subject to variation.  As a medical 
royal  college  we  have  issued  guidance  on  clinical  responsibility  for  patients  who  are  located  in  the 
emergency department but who have been seen by and are under the clinical care of a team other than 
the emergency medicine team.  This guidance states “Once a patient in the ED is seen by a specialty 
team, then that patient becomes the responsibility of the specialty team” [3].  This guidance was issued 
to ensure that emergency department doctors are able to prioritise the assessment and treatment of 
newly  arrived  patients  in  a  timely  fashion. 
It  is  not  the  role  of  emergency  medicine  doctors  to  be 
undertaking risk assessments that specifically relate to the hospital admission process; this is the role 
of the admitting specialty doctors, even when the patient is still in the ED.  We would however expect 
emergency department doctors to undertake a VTE risk assessment for those patients who are being 
admitted for a prolonged period under  the care  of  the ED team to  a clinical area such as a Clinical 
Decision Unit or Observation Ward run solely by the emergency department. 

We note your concern around the potential for confusion with regards the timing of the risk assessment 
however, as described above, these are issues for the admitting specialities and we feel it would be 
inappropriate to comment further. 

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 Yours sincerely, 

RCEM Quality in Emergency Care Committee Chair 

References 
[1] https://rcem.ac.uk/wp-content/uploads/2024/01/RCEM_Crowding_Guidance_Jan_2024_final.pdf. 
Accessed 07.05.2024. 

[2] https://www.hssib.org.uk/patient-safety-investigations/harm-caused-by-delays-in-transferring-
patients-to-the-right-place-of-care/. Accessed 07.05.2024. 

[3] https://rcem.ac.uk/wp-
content/uploads/2023/10/RCEM_Positon_Statement_Clinical_Responsibility_for_Patients_within_the 
_Emergency_Department.pdf. Accessed 07.05.2024. 

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Care Quality Improvement Directorate 
Royal College of Physicians 
The Spine 
2 Paddington Village 
Liverpool L7 3FA 

Heidi J Connor 
Senior Coroner for Berkshire  
Berkshire Coroner’s Office 
Reading Museum and Town Hall 
Blagrave Street 
Reading 
RG1 1QH 

27 June 2024 

Dear Ms Connor 

Report to Prevent Future Deaths E Mercer 26.04.2024 

We note the content if your Regulation 28 report for the prevention of future deaths related to the death of 
Ellen Mercer.  

We send our sincere condolences to the family.  

You note prolonged delay to be admitted to hospital, and the consequent delay in receiving prophylactic 
therapy for  venous thrombo embolism.  This may have resulted in fatal pulmonary embolism. You also note 
that current guidance is for this to be assessed within 24 hours of admission.  In the current circumstances 
with substantial delays in patients being admitted from emergency departments, sometimes for more than 
24 hours, this creates delays in treatment that can be life-saving.  

We note that the Royal College of Emergency Medicine has produced guidance on the clinical responsibility 
for patients who have been accepted for admission.  Unfortunately this guidance was produced without 
endorsement from admitting specialities, and therefore may not have been widely implemented.  

Each hospital will differ in the delays for admission, and the relative capacity of clinical teams.   

In the current context of delays for admission we do not believe that timing interventions from admission is 
appropriate, and these should be modified as timings from attendance or speciality referral.  Each hospital 
should have a local policy that agrees on clinical responsibility for patients waiting for admission in 
Emergency Departments. 

© Royal College of Physicians 
Registered charity no 210508 

 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In light of this case we will produce a Safety Alert for Physicians, and also liaise with NHSE England National 
Clinical Director for Urgent and Emergency Care, National Clinical Director for Patient Safety and The Society 
for Acute Medicine.  

Yours sincerely 

Clinical Vice President