Daniel McCallum Keane
9 Jun 2014 · Coroner Kevin McLoughin · Manchester (West)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate record keeping
“HE cs called to give evidence at the Inquest. He accepted in the course of his evidence that his record keeping was inadequate. He could not say from either his records or his recollection who had arranged for diabetic medication or citalopram to be prescribed or 29"" September 2010.”
2. failure to act on urgent referral request
“had no recollection or contemporaneous record of a telephone conversation with a neuropsychologist called on 8" November 2010 in which she said she ere to [the deceased]'s situation, which she described to him and indicated it was very worrying. EEE asked him to make an urgent referral to the district nurses as she was concerned he was not reliable in managing his insulin himself. [I said he could not refer to the district nurses. Despite having been put on alert in this telephone conversation [”
3. lack of supervision for high-risk patient
“At this time EE as in possession of various reports including a Multi- Disciplinary Team Discharge Summary dated 2 September 2010 that concluded [the deceased] was at extreme risk to himself and was not a safe option to live by himself without supervision.”
4. inadequate community management of Type 1 diabetes
“Consideration of the role of GP's generally in relation to the management of Type 1 diabetic patients in the community.”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“He accepted in the course of his evidence that his record keeping was inadequate.”
Later report
“Staff failed to keep an acute and contemporaneous note of the events that occurred with timings.”
Responses
2014-0260-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action
“A review of record keeping at HEE practice”