Edith Kirkham
23 Feb 2016 · Coroner John Pollard · Manchester (South)
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. inadequate planning and unclear rules for management
“intermediate care arrangement at Darnton House, | was informed, was a joint venture between L and M Health care and Tameside Hospital, but there seems to have been inadequate planning and unclear rules as to the level and type of management required for the patients/residents. Was the required standard that of a hospital or that of a care home. No-one seemed to know and this led to general uncertainty”
2. inadequate staffing
“Perhaps as a result of the problems highlighted at (1) above, the ward appears to have been inadequately staffed, both as to numbers of staff and the level of expertise thereof.”
3. failure to mobilise patient
“The staff, or some of them, who gave evidence at the inquest, had either failed to read the medical/nursing notes, or if they had so read them, they had failed to understand them. The consultant surgeon had clearly indicated that the patient was to mobilise and was able to fully weight- bear, however for the whole of the week she spent in this ward she was nursed in bed and not mobilised at all.”
4. lack of patient handover
“There was no apparent handover from the hospital to this ward, as to the individual needs of the patient, and the staff were therefore placed in an impossible position.”
5. delayed physiotherapy
“Mrs [name redacted] was moved to the intermediate care ward ona Friday preceding a bank-holiday weekend, and despite the clear indication that she was to have physiotherapy, none was arranged for four days after her arrival.”
6. missing records
“Despite the request from me as HM Senior Coroner, it appears that no records were available relating to the whole of her stay in this ward.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“There was generally poor communication between nursing and medical staff (inter se) and between medical/nursing staff and the family of the patient.”
This report
“There was no apparent handover from the hospital to this ward, as to the individual needs of the patient, and the staff were therefore placed in an impossible position.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“There was extremely poor communication between hospital staff and the patient (and her family), and between and amongst themselves. There was evidence of a lack of handover between staff, and this was exacerbated by the fact that the medical and nursing notes were frequently inadequate.”
This report
“There was no apparent handover from the hospital to this ward, as to the individual needs of the patient, and the staff were therefore placed in an impossible position.”