Nadia Wyatt
15 Jan 2024 · Coroner Rebecca Mundy · Essex
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. incomplete referral outcomes documentation
“Failure to update [the deceased]'s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for [the deceased] or her carer.”
2. missing readmission decision rationale
“Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale.”
3. inappropriate care plan duplication
“Evidence of "cutting and pasting" into [the deceased]'s care plan from another patient's care plan.”
4. risk assessment omission
“Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was.”
5. over-reliance on carer
“The potential for over-reliance on [the deceased]'s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining [the deceased]'s care and treatment in the community with the need to support her carer as well.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“Significant examples of cut and paste including out-of-date risk information at all grades of ward staff, and”
This report
“Evidence of "cutting and pasting" into [the deceased]'s care plan from another patient's care plan.”
Responses
2024-0024-Response-from-Essex-Partnership-NHS.pdf ↗· Essex Partnership NHS Foundation Trust
Stated action · April 2024
“The Trust has revised line management supervision forms to include quality of record keeping, their professional responsibilities, Trust policy and values, and NMC accountability frameworks in respect of record keeping. In addition to discussions during supervision the Crisis Response and Home Treatment Service has been reminded of this in their team meetings.”
Stated action · April 2024
“Bespoke training on the importance of documentation is being arranged for all staff working in the urgent care pathway in April 2024.”
Stated action
“The Home Treatment Team complete gate keeping assessments which provide professional opinions and rationale, including the 'purpose of admission', or a home treatment care plan as an alternative to admission. All admission requests have oversight from the Purposeful Admission Clinical Lead.”
Stated action
“The Trust is currently commissioning a unified Electronic Patient Records System. This system will permit access to all of the required clinical systems and will also embed a new mechanism to ensure robust clinical information sharing.”
Stated action
“The Trust's Urgent Care and Inpatient Care Unit is implementing a new initiative 'International Fundamentals of Care Framework', which is a nursing framework that supports transition and care planning based on trusting therapeutic relationship, integration of care and context of care.”
Stated action
“The Home Treatment Team in Mid and South have added the framework principles to the Newman's form that is given to patients to develop and assist with their view and planning of their care and treatment needs.”