Agnes Hannan

1. 1. lack of hospital notes and records

   “There was an actual, or perceived, lack of availability of the hospital notes and records of previous diagnoses and treatments by hospital doctors, for the staff working in the Emergency Department.”

2. 2. dislodged cannula tube causing soaked bed and inadequate hydration

   “On one occasion whilst she was an in-patient, Mrs [name redacted] who was desperately ill and needing intra-venous hydration, was found to be lying in a soaking wet bed because the tube leading to her cannula had become dislodged and disconnected. The nursing staff had failed to notice this problem. The doctors in evidence, acknowledged that her lack of hydration would inevitably have worsened her already thrombosed veins.”

3. 3. poor communication and inadequate handover

   “There was extremely poor communication between hospital staff and the patient (and her family), and between and amongst themselves. There was evidence of a lack of handover between staff, and this was exacerbated by the fact that the medical and nursing notes were frequently inadequate.”

4. 4. failure to consult long-term care provider

   “Whilst it was, or sho n apparent that she was already under the long term care il no-one made any attempt to speak with him or his department for advice.”

5. 5. use of unexplained abbreviations in notes

   “Throughout the hospital notes for this patient, there is widespread use of initials and abbreviations. On at least one occasion in court, none of the medical/nursing staff present could explain to me what the abbreviation in the notes meant.”

6. 6. absence of nursing observations for 24 hours

   “This patient needed very careful monitoring at all times and yet there was a period of 24 hours when no nursing observations were carried out or recorded.”

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