Kenneth Whittington
14 Feb 2019 · Coroner Veronica Hamilton-Deeley · Brighton and Hove
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. no junior doctor present during pre-operative assessment
“Mr. [name redacted] initial operation was abandoned because on his pre operation assessment on the 23 March 2018 there was no Junior Doctor present”
2. lack of post-operative catheter management instructions
“Most importantly post operation 'paperwork' contained no instructions regarding the management of his urinary catheter or how long it was to remain in situ”
3. epidural disconnection unmonitored causing uncontrolled pain
“Immediately post operatively Mr. [name redacted] epidural became disconnected. He complained of increasing pain over the ensuing night and in spite of this nobody, not even the most senior Nurses, ever checked his epidurall”
4. incomplete discharge documentation
“Mr. [name redacted] was due to be discharged on the 4" May. His discharge documentation which acts as a handover for his Doctors was barely completed and this lack of completion is unacceptable”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“(1) That the Discharge procedure followed in respect of Mr. [name redacted]' discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4”
This report
“(6) Mr. [name redacted] was due to be discharged on the 4”
Closely relatedConfidence 0.92 · high
Earlier report
“Handover was incomplete and unhelpful.”
This report
“His discharge documentation which acts as a handover for his Doctors was barely completed and this lack of completion is unacceptable.”
Closely relatedConfidence 0.90 · high
Earlier report
“handover relies more and more on the notes and the notes are relying more and more on tick boxes”
This report
“Mr. [name redacted] was due to be discharged on the 4”