Kenneth Horne
3 May 2018 · Coroner Margaret Jones · Stoke-on-Trent & North Staffordshire
The coroner's concerns
1. falls not communicated during transfer
“The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter.”
Responses
2018-0131-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust.pdf ↗· Royal Stoke University Hospital
Stated action
“All Clinical Leads to instruct Junior Doctors and Nurse [name redacted] that when summarising discharge letters, any significant event such as patient falls while in hospital is reflected on their discharge summary.”
Stated action
“Ward staff to ensure that alongside the paper version of handover between UHNM and other hospitals, a verbal handover happens as part of a trusted assessment.”
Stated action
“The Transfer of Care Form has now been revamped and a more comprehensive and holistic Patient Profile documentation is in place. This is a more detailed handover and requires other members of the multi-disciplinary team to contribute in its completion.”
Stated action
“This incident was already shared widely across the General Medicine Department and Medical division. A Memo has been circulated divisionally to reiterate the importance of accurate and timely datix reporting.”