Malcolm Rathmell
20 Feb 2019 · Coroner Jane Gillespie · Nottinghamshire
The coroner's concerns
1. incorrect warfarin prescribing
“Mr [name redacted] was treated and reviewed by a number of medical professionals from various disciplines between 14.03.18 and 22.03.18. No one identified during that time that he was being prescribed warfarin incorrectly”
2. mislabelled anti-coagulation chart
“It has not been possible to identify when Patient B's anti- coagulation chart was labeled with Mr [name redacted] details, save that it is likely, on the balance of probabilities, that it took place on ward B3 between 1.30pm on 15.03.18 and 4.06am on 16.03.18”
3. lack of pharmacy review
“There was no ward based pharmacy review between 15.03.18 and 22.03.18”
4. insufficient corrective actions
“The proposed actions being considered by the Trust to address the issue of incorrect prescribing are in their infancy and other than sharing the learning from the SI report, no other changes or action has been implemented to address the risk of future deaths”
Responses
2021-0059-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Nottingham University Hospitals NHS Trust
Stated action · 2019/20 - 2023/24
“The NHS Long Term Plan and NHS Mental Health Implementation Plan 2019/20 - 2023/24, commits to new and integrated models of care between crisis, acute, primary and community services.”
2021-0059-Response-from-North-East-London-NHS-Foundation-Trust.pdf ↗· Nottingham University Hospitals NHS Trust
Stated action
“Provision of record keeping training to staff on Turner Ward to ensure that staff are reminded about the Trust's expectations in respect of the record keeping”
Stated action
“Development and implementation of a discharge checklist to ensure that the discharge procedure safeguards patients' clinical needs more robustly and supports healthcare staff”
Stated action
“Audits to monitor implementation of the discharge checklist”
Stated action
“Update of the HTT Service Operational procedure to ensure that the patients are not discharged without HTT or ACAT assessment, in the cases where there is a suggestion that the patients may benefit from HTT service input”
Stated action
“Update to Trust's Clinical Handover of Care and Discharge Policy to ensure that the discharges take place more safely and effectively, and the referrals have been effectively completed to address the clinical needs of the patient as required”