Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Jean James · 13 Mar 2014 · Derek Winters, Sunderland
“The time taken to complete the initial documentation was longer than it ought to have been given the interruptions to the process.”
judiciary.uk/prevention-of-future-death-reports/jean-james-2
What was promised
Stated action 1 · response to Jean James (13 Mar 2014) · stated timescale: end of May 2014
“the Trust has undertaken the following actions: 1) We have reviewed the hospital information system, known as MEDITECH V6 to find a solution to prevent further risk for patients who on assessment are at risk of developing a venous thromboembolism episode (VTE). The proposal is for the VTE assessment screen to automatically move to the prescription screen if a patient has been identified as being at risk. The medical staff will be required to complete the prescription for the thromboprophylaxis”
judiciary.uk/…/2014-0112-Response-by-City-Hospitals-Sunderland.…
Stated action 2 · response to Jean James (13 Mar 2014) · stated timescale: none stated
“2) We have introduced a new format for clinical handover of patients from the Acute Medical Unit to their base ward. This acuity handover tool is patient focused and highlights key indicators regarding the patient's healthcare needs, and treatment plan.”
judiciary.uk/…/2014-0112-Response-by-City-Hospitals-Sunderland.…
Stated action 3 · response to Jean James (13 Mar 2014) · stated timescale: none stated
“3) Communication between the pharmacy team and escalation of omissions is currently the subject of an internal review where the team are in the process of identifying workable solutions.”
judiciary.uk/…/2014-0112-Response-by-City-Hospitals-Sunderland.…
1 further stated action is listed on the full chain page.
What recurred
- 24 Sept 2014 · Leonard Hudson · coroner not stated · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Jean James · 13 Mar 2014
“The time taken to complete the initial documentation was longer than it ought to have been given the interruptions to the process.”
Later · Leonard Hudson · 24 Sept 2014
“The nursing documentation was not as comprehensive as it ought to have been.”
What happened next
No web check of the stated actions has been published for this chain.