Evelyn Ross
27 Apr 2020 · Coroner Alison Mutch · Greater Manchester South
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. staffing shortages leading to reliance on agency and less experienced staff
“The inquest was told that the ward in question had been short staffed for a number of months. As a result there was a reliance on agency staff and less experienced staff. The trust was now seeking to resolve the issue but it was still not fully resolved. It reflected a wider issue of a national shortage of nurses.”
2. delayed discharge due to lack of community care package
“The inquest was told that whilst Mrs [name redacted] was medically fit for discharge prior to 1st July she had not been discharged because of delays in arranging a suitable care package to support her in the community.”
3. inadequate documentation of patient condition and decisions
“During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions.”
4. non-compliance with falls risk policy
“The inquest heard that the Trust had not followed their own falls risk policy in relation to Mrs [name redacted].”
5. absence of regular orthogeriatric consultant reviews
“There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs [name redacted]. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs [name redacted]”
This report
“During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions.”
Closely relatedConfidence 0.90 · high
This report
“During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions.”
Later report
“The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various stages of [the deceased]'s treatment. The extent of these lapses meant staff who made important treatment decisions could not be identified, and where staff could be identified, no contemporary account of their rationale for making treatment decisions could be located.”
Closely relatedConfidence 0.90 · high
This report
“During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions.”
Later report
“The GMMH documentation was of a poor quality and did not capture key discussions/decisions including in relation to medication.”
Responses
2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · deferred until operational effort to COVID-19 response
“The NHS published the Interim People Plan1 in June 2019 that sets out the long-term vision and immediate actions to meet the challenges of workforce supply, reform, culture and leadership. Publication of the final NHS People Plan has been deferred so that the NHS is able to devote its full operational effort to the COVID-19 response. However, when published, the final NHS People Plan will set out further actions to secure the NHS staff we need in the future.”
2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf ↗· Manchester University NHS Foundation Trust
Stated action · March 2020
“The Trust has an established process in place to review nursing workforce establishments and skill mix for all wards. This utilises an evidence-based triangulated approach to determine nurse staffing levels and skill mix, that reflect patient acuity and dependency requirements to inform workforce planning. The Safer Nursing Care Tool (SNCT) is utilised to gather patient acuity and dependency data over a four-week period. Ward 6 completed data collection periods in March, June and September 2019 and”