Brian Francis

4 Mar 2015 · Coroner Sarah-Jane Richards · Powys, Bridgend & Glamorgan Valleys

The coroner's concerns

1. failure to review patient by Consultant
“The process of a Consultant's attendance on patient being noted by a 'tick in the box' on a paper record failed. The box had been ticked when in fact the patient had not been reviewed by the Consultant.”
2. unavailable community medical records
“Had the Community medical records been available at the time of hospital admission the patient would most probably have been assessed differently and in all probability, anti-coagulation therapy commenced immediately or shortly thereafter.”
3. delayed Consultant review
“Ensuring patients once 'clerked' within emergency medicine have prompt Consultant review.”
4. lack of notification to ward staff
“Notification that the review has occurred to be indicated to Ward staff.”
5. inaccessible electronic community records
“For Community Health Care records to be electronically available to Emergency Medicine Departments”