David Cooper

21 Dec 2016 · Coroner Andrew Barkley · South Wales Central

The coroner's concerns

1. lack of comprehensive hand-over during patient transfers
“When transfers between wards took place, the evidence revealed that there was a lack of comprehensive hand-over by the transferring ward to the receiving ward especially in terms of identifying the patient's risk of falls. For example, on ward 18 Mr [name redacted] was in receipt of”
2. incomplete nursing documentation of falls
“The accuracy and completeness of nursing notes and records left much to be | desired. For example, on Ward 21 when he fell three times, there was no entry made in the Falls Diary”
3. lack of joined up thinking about patient risk
“The evidence revealed that there was a distinct lack of”
4. inadequate staffing allocation for high risk patients
“As with many other cases involving patients at high risk of falls, the evidence revealed shortcomings in the system used for booking additional staff to provide”