Eileen Pollard
3 Mar 2020 · Coroner Abigail Combes · South Yorkshire (West)
The coroner's concerns
1. call bells not working
“The call bells are checked daily as part of routine maintenance however the document which records the checks is pre populated with a 'P' for pass. This could lead to rooms being missed in the checks or a failure to correct a 'P' to an 'F' in the event of a fail. It may be the case that in the event of another patient requiring a call bell and it not working this could make a significant difference to the outcome for that individual and for that reason the maintenance arrangements are important.”
2. lack of documentation of call bell checks
“During the course of the investigation my inquiries revealed matters giving rise to a concern. 5”
3. outcome unchanged despite call bell failure
“The medical evidence presented at inquest was clear that even if this was the case, the outcome for [the deceased] would not have been any different.”
Responses
No published response was found on judiciary.uk.