Agnes Sansom
7 Jan 2020 · Coroner Jeremy Chipperfield · County Durham and Darlington
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. important information not reaching relevant staff
“existing patient record systems fail to ensure that important and urgent information is brought, in a timely way, to the attention of those who need it”
2. shared walking aids pose fall risk
“vulnerable patients are obliged to share walking aids on hospital wards”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“existing patient record systems fail to ensure that important and urgent information is brought, in a timely way, to the attention of those who need it”
Later report
“The use of verbal handovers does not in my view fully address my concern that crucial medical information should be recorded in a patient's medical records in such a way that relevant information is visible to those involved in care.”
Responses
2020-0002-Response-from-County-Durham-and-Darlington-NHS.pdf ↗· County Durham and Darlington NHS Foundation Trust
Stated action
“The root cause analysis report has been reviewed and we have concluded that a misleading choice of words have been used as follows:”