Marc Poole
2 Feb 2016 · Coroner Nicola Mundy · South Yorkshire (East)
The coroner's concerns
1. communication failures
“Poor communication on a number of levels”
2. inaccurate scoring
“The observation chart was poorly completed”
3. absence of paediatric sepsis protocol
“consideration should be given to developing a protocol and guidance for those treating children”
4. ineffective dissemination of updates
“There needs to be a review of the systems currently in place for disseminating such information”
5. inadequate record keeping
“Even when a ward is busy, it is imperative that clear records are made of significant events or developments”
Responses
Marc-Poole-Response.pdf ↗· Doncaster and Bassetlaw NHS Foundation Trust
Stated action
“Staff have been made aware that at the inquest it was highlighted there were a number of poorly completed charts with incomplete scores during the episode of care. It was the case that temperature readings had been recorded without a corresponding record of the heart rate and respiratory rate being undertaken at the same time which will enable significance to be attached to the result and correctly identify scores. Any additional training needs for staff have been noted and are in process of be”