Lilian Behrendt
9 Jun 2022 · Coroner Jacqueline Lake · Norfolk
The coroner's concerns
1. lack of documentation of deteriorating condition
“The records relating to Mrs [name redacted] referred to her as being”
2. absence of mobile recording device for observations
“the Nurse taking the observations on 28 November 2021 did not have access to a mobile recording device”
3. lack of clear staffing accountability
“the Nurse in Charge had been "dismissed" following Mrs [name redacted] death”
4. inadequate multidisciplinary communication
“The Nurse in Charge had contacted another member of staff to comment on Mrs [name redacted] general presentation”
5. uncertain advance care planning documentation
“It was unclear from the Home records whether a DNACPR and a ReSPECT form were in place”
6. absence of clear leadership and accountability
“lack of ownership for overall running of the Home, with no one person having or taking responsibility and accountability for the residents”