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The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. This webinar will explore the findings from MNSI's investigations into first trimester deaths in England from venous thromboembolism associated with hyperemesis. Speakers: Dr Charlotte Frise Dr Louise Page Chandrima Biswas Kirsty MacLennan Register for the webinar

Blood clots, particularly deep vein thrombosis (DVT) and pulmonary embolism (PE), together venous thromboembolism (VTE), pose a significant health threat to patients. These potentially life-threatening conditions can manifest silently and without warning, making vigilance and knowledge crucial. In this Top picks, we’ve pulled together resources, blogs and reports from the hub for patients and healthcare professionals, which focus on how to recognise venous thromboembolism and how to improve patient safety. 1. Deep vein thrombosis: understanding and managing your risk In this blog, Jo Jerrome, CEO of Thrombosis UK, explains the dangers of DVT and why it is important for patients and staff to be aware of the risk factors. Jo offers advice on how we can all manage our risk of DVT. 2. HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the timely recognition and treatment of suspected pulmonary embolism in emergency departments. 3. Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. 4. Venous thromboembolism (VTE): deep vein thrombosis and pulmonary embolism VTE is a significant cause of mortality, long-term disability and long-lasting ill-health problems – many of which are avoidable. 1 in 20 people will have a VTE at some time in their life and the risk increases with age. This NHS Resolution guide provides more information about the risks of VTE and how to spot the common signs and symptoms. 5. HSIB - The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period final report This investigation by the HSIB explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. 6. NHS Resolution: Working to prevent avoidable venous thromboembolism VTE is an international patient safety issue and a clinical priority for the NHS. Around half of all cases of VTE are associated with hospitalisation, with many events occurring up to 90 days after admission. It is a leading and preventable cause of death in an estimated 25,000 of hospitalised patients each year. This information leaflet highlights the cost of VTE claims and what you can do in your organisation to prevent VTE. 7. Pulmonary embolism misdiagnosis – a systemic problem Tim Edwards is a risk management expert and son of Jenny, who passed away in February 2022 from pulmonary embolism, following a misdiagnosis. Frustrated by the quality of the initial investigation that followed her death and the lack of assurance that learning would take place, Tim conducted an independent review. In this opinion piece, Tim draws on his research to highlight the key patient safety issues, and to encourage further dialogue around the topic. 8. Let's Talk Clots! Help reduce your risk of DVT and PE in hospital with this simple app Download the free Let’s Talk Clots patient information app from Thrombosis UK, and help reduce your risk of DVT and pulmonary embolism in hospital. 9. Patient Safety Spotlight Interview with Beverley Hunt, Professor of Thrombosis and Haemostasis and founder of Thrombosis UK In this interview, Beverley Hunt talks about setting up Thrombosis UK and how it has grown to have a national impact on patient safety in hospitals. She also describes the value of combining policy work with seeing patients face-to-face, and explores the need to find new ways of working to deal with the pressures facing the healthcare system. 10. Risk assessment models for venous thromboembolism in medical inpatients This cohort study in JAMA Network Open aimed to determine the prognostic performance of the simplified Geneva score and other validated risk assessment models (RAMs) to predict VTE in medical inpatients. The study provided a head-to-head comparison of validated RAMs among 1352 medical inpatients. It found that sensitivity of RAMs to predict 90-day VTE ranged from 39.3% to 82.1% and specificity of RAMs ranged from 34.3% to 70.4%. The authors concluded that the clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies. 11. HSIB: Investigation into management of venous thromboembolism risk in patients following thrombolysis for an acute stroke This HSIB investigation focused on the management of VTE risk in inpatients following thrombolysis for an acute stroke detection of medical problems (that impact on VTE risk) occurring in inpatients following thrombolysis for an acute stroke. Do you have a resource or story to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.

Download the free Let’s Talk Clots patient information app from Thrombosis UK, and help reduce your risk of Deep Vein Thrombosis and Pulmonary Embolism in hospital.

Did you know venous thromboembolism (VTE), is an umbrella term for deep vein thrombosis  and pulmonary embolism? VTE is a significant cause of mortality, long-term disability and long-lasting ill-health  problems – many of which are avoidable. 1 in 20 people will have a VTE at some time in their life and the risk increases with age. This NHS Resolution guide provides more information about the risks of VTE and how to spot the common signs and symptoms. Read the guide via the link below

This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Beverley talks to us about setting up Thrombosis UK and how it has grown to have a national impact on patient safety in hospitals. She also describes the value of combining policy work with seeing patients face-to-face, and explores the need to find new ways of working to deal with the pressures facing the healthcare system.

In this blog, Jo Jerrome, CEO of Thrombosis UK, explains the dangers of deep vein thrombosis (DVT) and why it is important for patients and staff to be aware of the risk factors. Jo offers advice on how we can all manage our risk of DVT, and introduces their award-winning, free patient app – “Let’s talk clots”.   Are you at risk? Deep Vein Thrombosis (DVT) is a blood clot which has formed in the deep veins, usually in the legs. Often preventable, a DVT needs to be diagnosed and treated to avoid risk of a piece of the clot breaking off and travelling in the blood stream to the lungs where it can cause a life-threatening blockage known as a pulmonary embolism (PE). Risk factors for a DVT include: recent hospitalisation (especially for illness, surgery or trauma) cancer some cancer treatments prolonged immobility combined oral contraceptive pill hormone therapy when taken in tablet form pregnancy and up to six weeks postpartum a family history of thrombosis obesity smoking. Managing your risk of DVT Being aware of risk factors is really important in helping you to avoid and protect yourself from DVT. If you are aware you may be at risk of a blood clot, discuss this with your doctor or nurse. Keeping active, well hydrated and of healthy weight can also help reduce your personal risk of thrombosis. If there are medical risk factors – such as an active cancer or severe injury or trauma, then a doctor or nurse will assess your risk and may prescribe an anticoagulant to reduce the risk of a clot forming. Suspected or diagnosed DVT If you think you have signs or symptoms of a DVT or PE, it is vital to seek urgent medical advice for clinical investigations and diagnosis. If a blood clot is suspected or diagnosed, an anticoagulant medication is normally prescribed, usually in tablet form and this will need to be taken for at least three months, often longer depending on a clinical review and guidance. An anticoagulant – sometimes called a ‘blood thinner’ slows the body’s ability to form clots, hence reducing the risk of the clot becoming larger or more clots forming. This then reduces your risk while your body breaks down and dissolves the existing clot or clots. “Let’s talk clots” - free patient app Thrombosis UK has developed a medically approved information app – ‘Let’s Talk Clots’ which offers invaluable information on DVT and PE, including: symptoms information about risk factors diagnosis treatments help during recovery and restoring well-being after a diagnosis of a blood clot. Recovering after a blood clot? The app has information about recovery, including pain and breathlessness, managing anxiety and worry, regaining wellbeing, fitness and returning to everyday activities. Questions about life after a diagnosis of a blood clot? Information is shared about considerations around life events, including pregnancy, family planning, travel, work and managing other conditions or treatments alongside risk factors or a personal medical history of thrombosis. You can visit the Thrombosis UK website for more information about the app and how to download it.