Michaela Thompson
2 Nov 2016 · Coroner David Hinchliff · West Yorkshire (East)
The coroner's concerns
1. inadequate documentation of multi-disciplinary team meetings
“inadequately documented in the case notes. It should be clearly documented as to who was present and participating in such meetings. The identification of those involved should be clearly recorded, as should the outcome of and decisions made at such meetings.”
2. lack of recording of service calls
“Calls to the Service should therefore be recorded, to ensure that details of the nature of the calli; its urgency; and the action taken by a named individual or individuals can be clearly ascertained.”
3. potential future deaths due to systemic failures
“In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.”
Responses
2016-0392-Response-by-Leeds-and-York-NHS-Trust.pdf ↗· Leeds and York Partnership NHS Foundation Trust
Stated action
“we will of course put in place”
Stated action
“facility to record calls coming into clinical services is important”