Joan Talbot

“Mrs [name redacted] had been admitted on 3 occasions when a history of diarrhoea, at times bloody, was reported before her final fourth admission. On each occasion she came under a different admitting team. There were gaps in continuity of care such that the significance of her history of diarrhoea was not fully appreciated resulting in delays in this presentation being investigated.”

“Although the Trust has subsequently introduced a new record system that has the potential to assist with continuity of care, it has not asked itself how this system can be used most effectively to ensure continuity of care in this specific scenario, whether further refinements to the existing systems and processes may be required.”