Evelyn Swift
29 Aug 2019 · Coroner Elizabeth Didcock · Nottinghamshire
The coroner's concerns
1. patient triage
“The Beechdale Medical Group did not have safe procedures in place to triage patients when they presented as unwell”
2. home visit allocation
“The Beechdale group did not have safe procedures in place for the allocation of homevisits”
3. clinical availability
“The Beechdale group did not have an allocated clinician available each day that was accessible by the Practice team, and available to provide urgent clinical advice”
4. documentation
“The Beechdale Medical Group did not have safe processes in place to ensure that all calls from patients were documented, nor safe processes to ensure that contemporaneous notes made during a home visit were recorded on the patient record”
5. clinical capacity
“The Beechdale Group did not have sufficient clinical capacity to ensure safe clinical cover arrangements at each location where services are provided”
6. event review
“The Beechdale group did not have processes in place to review a significant event, such as a sudden death when there was Practice involvement on the day prior to the death, with no understanding of the need to review and learn as a Practice from such events”
Responses
No published response was found on judiciary.uk.