Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate record keeping compromising patient safety
The earlier warning
David Chatburn · 18 Mar 2014 · L J Hashmi, Manchester (North)
“That the GP's recollection of events was not supported by contemporaneous record keeping, thus calling into question accuracy.”
judiciary.uk/prevention-of-future-death-reports/david-chatburn
What was promised
Stated action 1 · response to Susan George (29 Feb 2016) · stated timescale: none stated
“The discharge assessment document is prepared prior to planned discharges and is then completed on the day of discharge by the discharge nurse. The final page of this document is the 'Discharge Plan' which contains the emergency contact numbers and a crisis contingency plan. A copy of this is handed to the patient upon discharge.”
What recurred
- 29 Feb 2016 · Susan George · Lisa Hashmi · Closely related · confidence 0.80 (moderate)
- 26 Jul 2018 · Astonn Mitchell-Male · Lisa Hashmi · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Susan George · 29 Feb 2016
“Poor record keeping, predominantly on the part of the nursing staff.”
Later · Astonn Mitchell-Male · 26 Jul 2018
“There was evidence to show that record keeping was poor and at some points non-existent.”
What happened next
No web check of the stated actions has been published for this chain.