Leslie Lerner
28 Oct 2016 · Coroner Veronica Hamilton-Deeley · Brighton and Hove
The coroner's concerns
1. inappropriate sling application
“Junior Doctor applied wrong sling with wrong knot for Mr [name redacted] after she had learned that he had had a fractured shoulder which was to be treated conservatively”
2. premature discharge without senior review
“Mr [name redacted] was kept in the Royal Sussex County Hospital overnight and i towards the middle of the day he was discharged without a Senior Review”
3. delayed analgesia administration
“Mr [name redacted] was back at the RSCH, by ambulance at 1006 hrs in considerable pain and discomfort.”
4. failure to implement orthopaedic recommendation
“Having been admitted to a renal ward, because of lack of beds elsewhere, a member of the medical staff had a telephone discussion with a member of the Orthopaedic Team and a collar and cuff sling was recommended. This information was not passed onto the Nursing Staff, not properly documented nor was the Patient actually seen by a member of Orthopaedic Team”
5. lack of continuity and hands-off care
“There is no evidence of any continuity of care.”
6. delayed recognition of sling-induced injury
“This was the day (nine days after its application) that hospital staff realised that the sling was incorrectly tied, and of the wrong type, and had caused a long deep Grade 2 pressure sore and necrotic ulcerated area where it had been pressing into the back of Mr [name redacted] neck”
Responses
No published response was found on judiciary.uk.