Leslie Pates
30 Jan 2014 · Coroner John Pollard · Manchester (South)
The coroner's concerns
1. breakdown in communication between hospital and family
“There has been a complete breakdown in effective communication between the hospital and the family of the deceased”
2. failure to consider family wishes before discharge
“Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient”
3. patient sent home with severe pressure sores
“The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress”
4. failure to consider family views in discharge plan
“Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge”
Responses
2014-0043-Response-by-Tamside-Hospital-NHS.pdf ↗· Tameside Metropolitan Borough Council
Stated action
“Develop a checklist to ensure all members of the Multidisciplinary Team (MDT) have engaged with patients and their family prior to discharge.”
Stated action
“To ensure all patients and families have every opportunity to discuss plans and have a dedicated name and contact number for the social worker managing their discharge.”
Stated action
“All patients returning home with care package will have their equipment needs assessed and documented in hospital.”
Stated action
“All plans of care for patients must be shared with the patient and, with patient's consent, their next of kin and agreed before discharge.”
Stated action · next 3 months
“A Pilot of "Sick Patients Home Other Plan" (SHOP) is in progress on two medical wards. This is to be escalated across the trust over the next 3 months and become embedded Practice.”