Anna Elliott
18 Jul 2024 · Coroner Melanie Lee · Inner North London
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate record keeping
“There were issues with record keeping across the board. Including, a telephone call from [the deceased]'s mother reporting concerning messages was not recorded or passed on; an entry relating to a different patient was recorded in [the deceased]'s records; staff were sharing log on details or not logging off from their account (also raising data protection concerns); and the written handover document was inadequate, failing to record vital information.”
2. inadequate observation charting
“The Trust's policy is very clear on what should be recorded on the safe and supportive observation charts. In addition, all of the witnesses could explain in evidence, the expectation and what good practice looks like. However, only one staff member's entries met this expectation. All of the other entries that I was taken to simply recorded [the deceased]'s location at the time of the observation. I heard evidence that observation records are audited for quality and entries raised with staff if they do”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“However, only one staff member's entries met this expectation. All of the other entries that I was taken to simply recorded [the deceased]'s location at the time of the observation.”
Later report
“Such concerns included: the level of detail in observation records not meeting the expectations of the Trust's own policy; the accuracy of timing's in some observations was questionable;”
Responses
2024-0386-Response-from-ELFT.pdf ↗· East London NHS Foundation Trust
Stated action · 2024-09-30
“The Tower Hamlets Crisis Services acknowledge that on 23 November 2021 the calls made by Ms [name redacted] mother to the Home Treatment Team (HTT) were not recorded in the RiO medical records or passed on. 6. Steps are now in place to ensure calls are not missed: the administrators' office will now be covered with admin staff during the team handover from 14:00 to 16:00 to ensure calls are not missed. 7. In addition, HTT staff will be offering carers and significant others a check-in/follow up call for”