Daniel Williams
6 Jan 2014 · Coroner Nicola Mundy · South Yorkshire (East)
The coroner's concerns
1. staff training gaps in record keeping and communication
“Quality of staff training, particularly with regard to record keeping and communication.”
2. holistic care approach imbalance
“The emphasis on taking a holistic approach to care and whether there is an imbalance between adopting such an approach and patient safety.”
3. lack of clear guidance on self-harm item checks
“The absence of clear guidance for checking patients and their rooms for potential self harm items both in the rooms themselves and for items brought into the hospital.”
4. missing reference sheet for key issues
“The absence of a single reference sheet in the notes summarising key issues, risk factors, significant incidents and concerns readily accessible to all involved in patient care.”