Linda Heath
9 May 2024 · Coroner Sally Robinson · East Riding and Hull
The coroner's concerns
1. lack of sufficient information in discharge summary
“The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary”
2. no post discharge referral for sacral sore
“no referral was made post discharge by the GP surgery”
3. absence of follow up trigger for deteriorating patients
“No trigger appears to exist whereby GPs conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their condition”
4. insufficient inquiry into private care package parameters
“An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers”