Renal vein thrombosis is a rare complication of acute pyelonephritis. We report a case of a 56‐year‐old woman with poorly controlled type 2 diabetes mellitus who presented with acute pyelonephritis and hyperglycaemic hyperosmolar state (HHS), complicated by thrombosis of the renal vein extending into the inferior vena cava. She was managed with intravenous antibiotics, intravenous fluids and insulin and with therapeutic low molecular weight heparin, despite which she developed pulmonary emboli two days after the diagnosis of renal vein and inferior vena caval thrombosis. Following optimisation of the dalteparin dose with factor Xa monitoring and a prolonged course of antibiotics, she made a full recovery. Two months post‐treatment there was resolution of the renal vein thrombosis and pulmonary emboli with improvement of inflammation of the right kidney on repeat computer tomography scanning. This case highlights the need to recognise renal vein thrombosis and pulmonary emboli as complications of acute pyelonephritis, especially in combination with poorly controlled diabetes mellitus, which further increases the hypercoaguable state. Copyright © 2016 John Wiley & Sons.

Introduction NICE and the National Osteoporosis Guidance Group (NOGG) advise on evaluation of fracture risk and osteoporosis treatment1,2, with evidence suggesting that screening and treatment reduces the risk of fragility fractures 3,4,5. However, it is often overlooked in the management of older patients within secondary care. Audit data from Sheffield Frailty Unit (SFU) in 2018 showed that national guidance was not routinely followed. Fracture Risk Assessment Tool (FRAX®) scores were not calculated and bone health was poorly managed. Therefore, we undertook a quality improvement project aiming to optimise bone health in patients presenting to SFU. Method & Intervention In January 2019 we collaborated with Sheffield Metabolic Bone Centre (MBC) to develop a pathway aiming to improve bone health assessment and management in patients presenting to SFU with a fall or fragility fracture. This included a user-friendly flow chart with accompanying guidelines, alongside education for staff. Performance was re-evaluated in May 2019, following which a tick box prompt was added to post take ward round documentation. A re-audit was performed in March 2020. Results In March 2018 0% of patients presenting with a fall had a FRAX® score calculated and only 40% of those with a new fragility fracture were managed according to guidelines. In May 2019, this had improved to 18% and 100% respectively. In March 2020 86% of patients had a FRAX® score calculated appropriately and 100% of fragility fractures were managed according to guidelines. In both re-audits 100% of FRAX® scores were acted on appropriately. Conclusions There has been a significant increase in the number of patients who have their bone health appropriately assessed and managed after presenting to SFU. However, achieving optimum care is under constant review with the aim to deliver more treatment on SFU, thereby reducing the need for repeat visits to the MBC.