Ann Swoffer
22 Jan 2019 · Coroner Louise Hunt · Birmingham and Solihull
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inconsistent practice and procedures
“practice and procedures in place at Good Hope Hospital at the time were not consistent with accepted practice or national guidelines”
2. late perforation causing deterioration
“The deceased deteriorated as a result of a late perforation over the August Bank Holiday weekend”
3. non‑compliance with BSG guidelines
“The department caring for the deceased at the time were not following accepted practice or BSG guidelines”
4. lack of integrated protocols across sites
“There is a general concern that all sites with the Trust are not integrated and are not following the same protocols”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“There is a general concern that all sites with the Trust are not integrated and are not following the same protocols.”
Later report
“Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding.”
Responses
2019-0026-Response-by-University-Hospitals-Birmingham-NHS-Trust.pdf ↗· University Hospitals Birmingham NHS Foundation Trust
Stated action · June 2019
“The Trust now have in place a single MDT to support decision making in oesophago- gastric cancer care, however for the purposes of care delivery there are currently two teams. The work to establish a single service for all aspects of care is in train and will be in complete by June 2019.”