Edward Cowey
14 Oct 2020 · Coroner Emma Serrano · Derby and Derbyshire
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of integrated transfer information
“Evidence emerged during the inquest 1. That patient electronic and paper based transfer information is not kept on one database. Mr [name redacted]' handover notes were kept on extra Med, his neurological observations on Patient Track and the falls form on his hard copy notes;”
2. inconsistent local head injury policy
“Trust local policy regarding treatment for head injures is not consistent with NICE Guidelines and doctors cannot be expected to be aware of all trust local policies;”
3. inadequate anticoagulation guidance
“Anticoagulation guideless do not cover a situation where anticoagulation is being given as a preventative measure as opposed to a treatment;”
4. falls form lacks guidance direction
“The Trusts local falls form does not direct doctors to the relevant guidance regarding head injuries simply asks if a CT head scans indicated”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“Evidence emerged during the inquest that the electronic transfer information is the only information that the receiving ward is given before a patient is transferred.”
This report
“Evidence emerged during the inquest 1. That patient electronic and paper based transfer information is not kept on one database.”
Closely relatedConfidence 0.90 · high
This report
“That patient electronic and paper based transfer information is not kept on one database.”
Later report
“There was no clear detailed handover or transfer document which would have detailed his medication, medical history and history of recurrent falls”