Brian Shillinglaw
6 Nov 2015 · Coroner Veronica Hamilton-Deeley · Brighton and Hove
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. incomplete or inaccurate care plan and risk assessment
“The creation of Care Plan, Risk Assessment and other admission | documentation”
2. lack of timely updates to risk assessment
“The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff”
3. inadequate communication among multidisciplinary team members
“A discussion about the role of the primary nurse and care coordinator which particular reference to ensuring ongoing communication between the various members of the multi-disciplinary team who will look after a patient like Mr [name redacted]”
4. non-compliance with trust risk assessment policies
“Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr [name redacted] | case”
5. inadequate dynamic risk assessment documentation
“The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation”
6. failure to implement observation policy and record status accurately
“Understanding the necessity of implementing the Trust's Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient's status is recognised and recording it correctly in all paperwork”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The consideration of, contribution to and preparation involved in risk care planning for Mr [name redacted] was insufficient in its scope and depth”
This report
“The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff”
Closely relatedConfidence 0.90 · high
This report
“The creation of Care Plan, Risk Assessment and other admission | documentation (2) The amending and updating of these plans”
Later report
“Nursing records, handovers, risk assessments and care plans were often incomplete, insufficient and at times contradictory.”
Responses
No published response was found on judiciary.uk.