Kathleen McGeary
26 Feb 2019 · Coroner Stephanie Haskey · Nottinghamshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate assessment of vulnerable patient with dementia
“There was little evidence that Mrs [name redacted] (who suffered from dementia and was vulnerable) was fully and properly assessed, investigated, diagnosed and treated before discharge”
2. unclear discharge responsibility
“No clinician took clear responsibility for discharge decision making. The recording of the identity of the discharging clinician was incorrect and communication between clinicians and nursing staff was unclear”
3. inadequate discharge documentation
“The electronic discharge summary was inadequate and no paper discharge summary was produced. No explanation was given for this omission”
4. missing prescribed antibiotics at discharge
“Mrs [name redacted] left hospital by hospital arranged transport without the antibiotics she had been prescribed for a suspected UTI. No explanation was given for this failing”
5. culture of acceptance of systemic failures
“At Inquest there appeared a culture of acceptance of the above failings and omissions without any corresponding will or effective plan to address them”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“No clinician took clear responsibility for discharge decision making. The recording of the identity of the discharging clinician was incorrect and communication between clinicians and nursing staff was unclear.”
Later report
“Lack of Named/Responsible Consultant review prior to a child's discharge”
Responses
2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust.pdf ↗· Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Stated action · now
“We have developed a new CDU(Clinical Decision Unit) standard operating procedure, which | attach, where it makes clear where responsibility lies for various aspects of the patient pathway. It also has CDU pathway document that aids the communication between the main hospital department and CDU on admission. This has now been implemented.”