Inadequate audit of observations and documentation

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2013 → 2021Jude Lloyd7 years 10 months after Stephanie Daniels · same coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight a lack of effective audit or oversight to ensure that existing policies are followed in practice. The earlier report stresses the need for audit to make handover procedures work, while the later report notes absent audit for compliance with record‑keeping and risk‑assessment protocols.

  Stephanie Daniels · 13 Dec 2013

  “without appropriate audit and clinical/nursing leadership this may prove to be ineffective.”

  Check it in the source

  Jude Lloyd · 4 Oct 2021

  “There was no robust audit system for checking compliance with the Trusts own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.”

  Check it in the source

  Stated action in the response to the earlier report

  “A revised governance process has been developed within the Citywide Commissioning, Quality and Safeguarding Team and the Trust now attends an established Citywide Patient Safety Committee. This committee meets monthly and is responsible for the review and monitoring of serious incidents requiring investigation reported by the Trust as well as any other patient safety related issues including those highlighted at inquest via Prevention of Future Death Reports.”

  Earlier report in the app · Later report in the app

• 2021 → 2022Rowan Thompson1 year 1 month after Jude Lloyd · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that the Trust's audit system for checking compliance with its own policies and procedures is inadequate and ineffective. The earlier report cites a lack of robust audit for medical record keeping, risk assessments and reviews, while the later report states that the system for auditing observations and documentation lacks rigour.

  Jude Lloyd · 4 Oct 2021

  “There was no robust audit system for checking compliance with the Trusts own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.”

  Check it in the source

  Rowan Thompson · 1 Nov 2022

  “System by which observations and documentation are audited lacks rigour and is ineffective.”

  Check it in the source

  Earlier report in the app · Later report in the app