Jean James
13 Mar 2014 · Coroner Derek Winters · Sunderland
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed initial documentation
“The time taken to complete the initial documentation was longer than it ought to have been given the interruptions to the process.”
2. failure to review prescription omission
“The omission to prescribe prophylactic Dalteparin had not been subject to any effective review by a clinician or a nurse.”
3. ineffective communication of pharmacy query
“When the pharmacy raised a query, it was not communicated effectively.”
4. insufficiently robust systems and protocols
“Systems, forms, checklists, policies, procedures and protocols and compliance with them may not be sufficiently robust to deal with human factors.”
5. unaddressed systemic failures
“The failures prevailed without correction from 24 December until Mrs [name redacted]' acute deterioration and death on 8 January 2014.”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“The time taken to complete the initial documentation was longer than it ought to have been given the interruptions to the process.”
Later report
“The nursing documentation was not as comprehensive as it ought to have been.”
Responses
2014-0112-Response-by-City-Hospitals-Sunderland.pdf ↗· City Hospitals Sunderland NHS Foundation Trust
Stated action · end of May 2014
“the Trust has undertaken the following actions: 1) We have reviewed the hospital information system, known as MEDITECH V6 to find a solution to prevent further risk for patients who on assessment are at risk of developing a venous thromboembolism episode (VTE). The proposal is for the VTE assessment screen to automatically move to the prescription screen if a patient has been identified as being at risk. The medical staff will be required to complete the prescription for the thromboprophylaxis”
Stated action
“2) We have introduced a new format for clinical handover of patients from the Acute Medical Unit to their base ward. This acuity handover tool is patient focused and highlights key indicators regarding the patient's healthcare needs, and treatment plan.”
Stated action
“3) Communication between the pharmacy team and escalation of omissions is currently the subject of an internal review where the team are in the process of identifying workable solutions.”
Stated action · autumn
“4) The Trust has a VTE policy based on NICE guidelines and we are currently reviewing the policy to encompass the technical changes made to the VTE assessment and prescribing process. We will hold a Trust wide clinical symposium in the autumn to ensure staff have the opportunity to discuss current issues regarding the management of patients at risk of VTE.”