Margaret Clement
14 May 2024 · Coroner Christopher Long · Lancashire and Blackburn with Darwen
The coroner's concerns
1. inadequate nursing records
“nursing records on Reedy ford ward were inadequate in a number of respects including recording the wrong medication, requesting a medical review for the wrong patient and not recording when an urgent review was needed in the doctor's task book.”
2. inadequate nursing handovers
“nursing handovers were inadequate and did not ensure appropriate risks were managed and prioritised”
3. ineffective task book prioritisation by doctors
“doctors on the ward did not effectively prioritise work by reviewing the task book in order to identify more urgent tasks”
4. failure to request medical review verbally
“Nursing staff failed to request medical review verbally were it was appropriate to do so, relying on a task book”
5. failure to seek urgent clinical assistance for per rectum bleed
“Nursing staff failed to seek urgent clinical assistance when presented with a significant per rectum bleed”
6. inadequate assessment of compliance with procedural changes
“Inadequate measures have been taken to assess compliance with procedural changes and expectations that have been set following the Trust investigation into this matter”