Rhys Hill
15 Jan 2024 · Coroner Alison Mutch · Manchester South
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. ineffective communication between clinicians and nursing team
“communication between clinicians and the nursing team on the neurosurgical ward was not effective”
2. incomplete documentation of patient information
“Documentation (clinical and nursing) was incomplete and did not detail key/important information about [the deceased]”
3. non-compliance with VTE policy and staff misunderstanding of requirements
“THE VTE policy was not fully followed and there was evidence that there was limited understanding by staff of precisely what the trust policy required in relation to reducing the risk at discharge of VTE”
4. lack of escalation protocol for omitted critical medication
“Despite a critical medicine being not given to [the deceased] there appeared to be no clear policy on how that would be escalated to a senior nurse/ treating clinician and how that escalation would be captured in the notes”
5. unclear medication reconciliation responsibility
“the system and responsibility between the hospital pharmacy and clinicians for reconciling medications given in the community with those given in the hospital to ensure all necessary medications were given was unclear”
6. unclear use of hospital passport system
“limited understanding amongst the nursing team of when a hospital”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“(2) There is no record in the medical records of that clinic appointment regarding what risks and benefits were discussed;”
This report
“Documentation (clinical and nursing) was incomplete and did not detail key/important information about [the deceased].”