Henry Powell
18 Feb 2015 · Coroner Lydia Brown · Leicester (City & South)
The coroner's concerns
1. inappropriate discharge care planning
“The discharge care planning was inappropriate and there was a significant misunderstanding regarding the intended and appropriate use of the bed rails which suggested insufficient training of discharge staff”
2. conflict between hospital and community transfer policies and equipment provision
“There is a conflict currently between the policies governing transfer arrangements between hospital (UHL) and community (LPT) and the provision and ordering of equipment”
3. inadequate coordination between services
“Co-ordination between services is inadequate, resulting in equipment being ordered by the hospital but not thereafter being followed up or assessed in the community”
4. lack of implemented alert system for stakeholder communication
“Equipment is supplied by a single gatekeeper, NRS Healthcare, and an alert system is intended to ensure communication has taken place between all stakeholders, but! was advised this system has not been implemented”