Kirsty Doodes
14 Oct 2021 · Coroner Andrew Cox · Cornwall and Isles of Scilly
The coroner's concerns
1. inadequate documentation of risk assessment
“Insufficiency of note-keeping”
2. inadequate risk explanation in discharge notes
“note made by Dr in the RiO records was described by an independent expert, Dr , as extremely brief. I accept that medical notes should not be defensive in nature but there is nothing at all in it to justify the view expressed that [the deceased] was safe to 1 Information Classification: CONTROLLED go home. In a context where she has, over a very recent period, attempted to on five occasions, the rationale explaining how it was felt she was safe to go home should, in my view, have been set out. Of perhaps”
3. lack of family involvement in discharge planning
“The Trust's own discharge policy states: 3. Principles The decision to discharge someone from hospital must be in keeping with the Care Programme Approach (CPA), (DH 1991, 2008) and governed by the following principles: The patient, carer and / or advocate, must be actively involved in all aspects of the discharge plan, where practicable. Arrangements for discharge should be negotiated with everyone likely to be concerned with the service user's aftercare. was [the deceased]'s carer. He had not been 'ac”
Responses
2021-0343-Response-from-Cornwall-Partnership-NHS-Foundation-Trust_Published.pdf ↗· Cornwall Partnership NHS Foundation Trust
Stated action
“we will prioritise the most important steps within the policy with a refreshed knowledge of the roles and responsibilities of the multi-disciplinary team. Our priorities around discharge are: - Communication with families and carers - Communication with the patient's GP - Medication - Care following discharge - Crisis information”