Paul Holmes
27 Jun 2024 · Coroner Stephen Covell · Cornwall and the Isles of Scilly
The coroner's concerns
1. lack of clear handover
“There was no clear, detailed and direct handover between doctors of the two hospitals”
2. lack of agreed treatment plan
“A treatment plan including the need to continue to treat [the deceased] for dehydration and what to do in the event of deterioration was not agreed and recorded clearly between clinical staff of both hospitals”
3. prescription error
“An error in the writing out of a prescription for intravenous fluids at the Royal Cornwall meant that the administration of hydrating fluids at Liskeard Community Hospital was delayed”
Responses
2024-0344-Royal-Cornwall-Hospitals-NHS-Trust.pdf ↗· Royal Cornwall Hospital Trust
Stated action · start of October 2024
“There are some additional safeguards in place for more complex presentations. In the scenario where a patient has needs which cannot safely be met by the nurse-led community hospital, an admission can be refused. There have also been cases, where the patient's needs are complex, where a doctor-to-doctor handover does take place. Given that there is very limited medical cover available at CFT community hospitals, it is not feasible to change practice to insist on doctor-to-doctor handovers for”