Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate documentation hindering clinical communication
The earlier warning
Margaret Postill · 21 Dec 2017 · Alison Mutch, Manchester (South)
“The documentation held by Tameside Hospital relating to the second visit was of poor quality .In particular there was a lack of detail around the decision making.”
judiciary.uk/prevention-of-future-death-reports/margaret-postill
What was promised
Stated action 1 · response to Margaret Postill (21 Dec 2017) · stated timescale: end of November
“We would hope that once you have had a chance to consider this further information with respect to documentation within the ED Department you will be reassured that there is clear evidence that there is nota cultural acceptance of poor documentation with the ED Department and that the department, particularly the Senior Consultants, work hard to ensure that all clinicians fully understand their obligations with respect to documentation and where these expectations are not met, that action is taken”
judiciary.uk/…/2017-0382-Response-by-Tameside-and-Glossop-NHS-T…
What recurred
- 10 Jan 2019 · Michael Flynn · Alison Mutch · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Margaret Postill · 21 Dec 2017
“The documentation held by Tameside Hospital relating to the second visit was of poor quality .In particular there was a lack of detail around the decision making.”
Later · Michael Flynn · 10 Jan 2019
“The ward was staffed by ward doctors throughout the day but there was no documeniation to suggest communication between the ward doctors and nursing staff in relation to Mr [name redacted] and his deteriorating picture”
What happened next
No web check of the stated actions has been published for this chain.