Jude Lloyd
4 Oct 2021 · Coroner Nigel Meadows · Manchester City
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of diabetes monitoring and management
“No thorough comprehensive risk review and care plan was formulated in relation to his Diabetes monitoring and management prior to his discharge from the inpatient unit”
2. lack of mental capacity assessment
“No appropriate formal mental capacity assessments were made and properly recorded”
3. inadequate transfer and communication
“The transfer and communication process from inpatient care to the CMHT was inadequate and incomplete”
4. lack of GP contact during inpatient stay
“No appropriate contacts were made with the GP whilst the deceased was an in-patient to obtain relevant clinical information”
5. gap in specialist advice for physical health
“Whilst a psychiatric inpatient and suffering from a serious physical health condition which requires monitoring and treatment it was not possible to obtain appropriate specialist advice because the deceased was not an inpatient in hospital and was not registered with a GP in that area”
6. lack of audit system
“There was no robust audit system for checking compliance with the Trusts own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“without appropriate audit and clinical/nursing leadership this may prove to be ineffective.”
This report
“There was no robust audit system for checking compliance with the Trusts own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.”
Identical hazardConfidence 0.90 · high
This report
“There was no robust audit system for checking compliance with the Trusts own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.”
Later report
“System by which observations and documentation are audited lacks rigour and is ineffective.”
Responses
2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published.pdf ↗· Greater Manchester Mental Health NHS Foundation Trust
Stated action
“The Trust's RCA report highlighted that in respect of inpatient monitoring of Mr [name redacted] diabetes, the care plans and risk assessments were completed on signs and symptoms of hypoglycaemia, but it was recognised these were not tailored to Mr [name redacted] specific needs. A further recommendation was to raise awareness and education on monitoring for signs of diabetic ketoacidosis for CMHT staff. To address this an eLearning training package is in place in respect of supporting and monitoring physical”