John Dickinson
22 Jul 2021 · Coroner Sarah Watson · West Yorkshire Eastern
This report repeats 3 earlier warnings, and was raised again 4 times later. See the linked reports.
The coroner's concerns
1. inconsistent and lacking detail record keeping
“The record keeping was inconsistent and lacked detail on general wellbeing”
2. fragmented documentation
“The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained”
3. assumption about food refusal
“Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020”
4. oral advice not recorded
“Advice from the GP on 15th July 2020 were handed over orally at a 'huddle' and no record was kept as to this being mentioned”
5. lack of monitoring plan
“Following the GP's visit, no action plan regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring”
6. delayed deterioration assessment
“The inconsistent and sometimes non-existent record keeping meant that Mr [name redacted] was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before when he began refusing lunch and evening meal”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Staff failed to keep an acute and contemporaneous note of the events that occurred with timings.”
This report
“(1) The record keeping was inconsistent and lacked detail on general wellbeing.”
Closely relatedConfidence 0.90 · high
Earlier report
“Failed to keep accurate records.”
This report
“The record keeping was inconsistent and lacked detail on general wellbeing.”
Closely relatedConfidence 0.90 · high
Earlier report
“There were concerns that entries contained in Mr [name redacted] care plan were incorrect, including vital information contained on his weight monitoring sheet. Furthermore, the general quality of record keeping was poor.”
This report
“The record keeping was inconsistent and lacked detail on general wellbeing.”
Identical hazardConfidence 0.90 · high
This report
“The record keeping was inconsistent and lacked detail on general wellbeing.”
Later report
“Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete”
Identical hazardConfidence 0.90 · high
This report
“(1) The record keeping was inconsistent and lacked detail on general wellbeing.”
Later report
“Overall documentation at the home was limited and lacked detail”
Identical hazardConfidence 0.90 · high
This report
“(1) The record keeping was inconsistent and lacked detail on general wellbeing.”
Later report
“That there remain potential issues of poor record keeping. ii) There are concerns over the level of compliance of care plans”
Closely relatedConfidence 0.90 · high
This report
“The record keeping was inconsistent and lacked detail on general wellbeing.”
Later report
“The record keeping in the home appeasers to be inaccurate and inconsistent”
Responses
2021-0310-Response-from-CQC_Published.pdf ↗· Care Quality Commission
Stated action
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
2021-0310-Response-from-Sunnyside-Nursing-Home_Published.pdf ↗· Sunnyside Nursing Home