Christine Street
10 May 2016 · Coroner Veronica Hamilton-Deeley · Brighton and Hove
The coroner's concerns
1. lack of completed admission and fall documentation
“Documentation with regard to the admission document (which was not completed) and the doctors pro forma to document the fall on the 11" September 2015 (was not completed)”
2. inadequate specialling supervision
“Mrs. Street was being specialled. She was on arm's length observations and had been since just after her biopsy on the 28" August 2015”
3. violation of mental health observation policy
“The Trust policy on observations for patients with mental health illness (this lady was deemed | not to have”
4. failure to record clinical observations and recognize dying patient
“From the 12"" September 2015 the recording of doctor's visits, of nurses observations and the processes around the recognition of the dying patient were utterly flawed”