Donald Clegg
8 Aug 2018 · Coroner Lisa Hashmi · Manchester (North)
The coroner's concerns
1. insufficient communication/transfer of care
“Communication/transfer of care/handover between social services, the first placement and/or the final placement was insufficient, given the complexities of the deceased's case”
2. inadequate assessment of care needs
“The process of assessment of care needs prior to admission was inadequate”
3. inadequate medicine policy and training
“Medicine Policy &/or ii)Medicine administration training, supervision and audit processes at Persona were inadequate and unsafe (indeed, the audit process was perfunctory”
4. failure to recognise deterioration and seek timely medical attention
“Staff were unable to recognise the deteriorating adult and did not seek medical attention in a timely manner when signs of change became apparent”
5. inadequate record keeping
“Record keeping was inadequate and in parts, incomplete”
6. absence of observation/monitoring policy
“There is no policy/protocol for the observation/monitoring of service users e.g. when directed to do so by a medical practitioner”