Nicola Matthews
20 Aug 2013 · Coroner Dr R N Palmer · London (South)
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. incomplete documentation of ward round decisions
“the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented. The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round”
2. departure of patients without clear follow-up arrangements
“other patients may come to harm if allowed to depart in-patient care without clear follow-up arrangements”
3. inadequate documentation of decisions and follow-up arrangements
“important decisions are better documented and that follow-up arrangements are made clear and adequately documented”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented.”
Later report
“(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded.”
Closely relatedConfidence 0.90 · high
This report
“The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round.”
Later report
“The systems in place for safeguarding voluntary patients in respect of leave and recording the decisions was inadequate and decisions were largely communicated by word of mouth”
Responses
No published response was found on judiciary.uk.