John Lea
28 Nov 2017 · Coroner Lisa Hashmi · Manchester (North)
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. risk assessments not updated
“critical risk assessments had not been updated and/or completed (falls, cot sides etc.) There were missed opportunities to re-assess.”
2. communication breakdown
“Poor communication between the nursing team, with particular reference to 'bay tagging'.”
3. documentation gaps
“Gaps within the documentation/record keeping/missing entries by both doctors and nurses (including fluid balance charts for a patient in heart failure and subject to fluid restriction, risk assessments, care planning, rounding tool and medical attendance upon the deceased).”
4. failure to escalate
“No escalation when the on call doctor failed to attend following a marked change in the deceased's oxygen saturations.”
5. communication breakdown
“bo I u n t co b r y re t c h t e ly p c re a v lc io u u la s te e d arl N y E w W ar S ing sc s o c r o es re . to T o h l e (E N W E S W ), S y w et a m s i d st e a s k ig es ne w d ith to re a g d a d r r d es to s s m co is r t e ak c e a s lcu b l r a o t u io g n h s t”
6. policy non adherence
“Failure to adhere to Trust policy/protocol - prevention of falls, patient observation”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“No assessment of the risk factors in discharging the deceased was documented in the deceased's records.”
This report
“In this case, critical risk assessments had not been updated and/or completed (falls, cot sides etc.) There were missed opportunities to re-assess.”
Closely relatedConfidence 0.85 · high
Earlier report
“During the course of the inquest hearing it became apparent that the nursing tools (in particular, the 'Purpose T'), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate.”
This report
“Gaps within the documentation/record keeping/missing entries by both doctors and nurses (including fluid balance charts for a patient in heart failure and subject to fluid restriction, risk assessments, care planning, rounding tool and medical attendance upon the deceased).”
Responses
No published response was found on judiciary.uk.