Graham Watts
3 Apr 2014 · Coroner Veronica Hamilton-Deeley · Brighton & Hove
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. discharge procedure flaws
“the Discharge procedure followed in respect of Mr. [name redacted]' discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4" December 2014 was deeply flawed. There was no ongoing process of discharge.”
2. blank discharge paperwork
“The discharge paperwork was effectively blank.”
3. lack of discharge communication
“There was no communication as to the discharge, either with regard to the anticipated date of discharge or with the Nursing Home who were expected to receive him back or with [the deceased]' son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.”
4. environment change fall risk
“It is acknowledged and accepted that a change of environment increases the risks of fall.”
5. hip fracture leading to death
“Evidence was heard to the effect that if Mr. [name redacted] had not fractured his hip when he fell, he would not have died when he did.”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with the Nursing Home who were expected to receive him back or with [the deceased]' son.”
Later report
“* firstly the fact that there was very little evidence of any joined up thinking with regard to her care or to plans, either for her future treatment or for her future placement, or for discharge whilst in AMU”
Closely relatedConfidence 0.90 · high
This report
“(1) That the Discharge procedure followed in respect of Mr. [name redacted]' discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4”
Later report
“(6) Mr. [name redacted] was due to be discharged on the 4”
Responses
2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust.pdf ↗· Brighton and Sussex University Hospitals NHS Trust
Stated action · 27 May 2014
“the Trust has taken several steps, working closely with the Matron and ward manager responsible for the ward on these issues. It is the practice on this ward to hold a daily”