Brenda Gowan
25 Feb 2019 · Coroner Nadia Persaud · London (East)
The coroner's concerns
1. discharged home without adequate support
“[the deceased] was discharged home, less than 3 weeks after a moderately severe stroke, for a "trial period”
2. unassessed fall risk at night
“[the deceased] was at risk of falling at night. There is no evidence that the risk was fully assessed on discharge from hospital and no evidence of the family being provided with advice on how to manage the risk”
3. inadequate care plan adaptation
“The discharge plan was based upon [the deceased] being settled at night time. When the family reported that this had changed and that [the deceased] was "up a lot" - the care plan for [the deceased] should have been re-”
4. missing community support
“There were no community support arrangements in place for the family to access, as the OT services had no contractual arrangement in place with [the deceased]'s registered GP”
5. equipment not provided before fall
“The equipment required for managing the risk of falls had not been provided prior to [the deceased]'s fall (5 days after discharge from hospital)”
6. absence of comprehensive discharge plan
“There was no comprehensive plan in place address key aspects such as how care would be provided during the trial period. Such a plan could include the risks identified and how they were to be managed; the equipment required and ensuring that it was provided, installed and those providing the care trained in its use and ensuring that community support is available. Such a plan should be discussed with the community carers (family in this case) and key aspects agreed with them before discharge”
Responses
2019-0064_Response-by-Barts-Health-NHS-Trust.pdf ↗· Royal London Hospital
Stated action
“Following the concerns raised by the family in regards to feeling that they lacked choice and support during the discharge process, there has been a review of the communication and documentation following a Family Care Planning Meeting ensuring that there is signed understanding of the expectations and actions by all parties. This reformatted documentation will support accountability and be uploaded to the electronic notes system and a copy given to the patient and family. This will include all”