Kathryn Millard
25 Apr 2022 · Coroner Ian Brownhill · Mid Kent and Medway
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of documented senior clinician direction
“The direction of the most senior clinician, the orthopaedic surgeon, was not documented in the medical records and was not implemented”
2. anti-embilic stockings not applied
“The medical records indicated that at least one doctor had indicated that Mrs [name redacted] should have anti-embolic stockings applied. However, the nursing staff gave evidence that they were not aware of this”
3. no entry for nursing concerns
“The nursing staff were concerned on the 12 May 2021 as to the presentation and prognosis of the deceased. Whomever attended (if they anybody did in fact attend), did not make any entry into Mrs [name redacted] medical records”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“Whomever attended (if they anybody did in fact attend), did not make any entry into Mrs [name redacted] medical records”
Later report
“At the inquest it was clear that the standard of record keeping by the medical staff was poor and it was only by hearing from witnesses via statements and orally, including from her family, that the decision making around her care and plans for her management became clear, as there was very little written in the notes.”
Responses
2022-0121-Response-from-Medway-NHS-Action-Plan.pdf ↗· Medway NHS Foundation Trust
Stated action · Nov-22
“Changing the set up of the clinical team on the ward will allow the hierarchical tree with Change the 'Ward based structure to team based.”
2022-0121-Response-from-Medway-NHS-Foundation-Trust.pdf ↗· Medway NHS Foundation Trust
Stated action · monthly
“The Trust has also taken action to ensure that Anti-Embolic Stocking (AES) are prescribed and applied when indicated by the medical team. Safety messages and local teaching have occurred to ensure that nurses escalate incidents where an appliance has been indicated, but not prescribed. Since the recipient of this letter, the team has again sent out safety message to all nursing staff as a reminder of the expected standard. Compliance with expected practice will be audited monthly, and monitored”