Richard Griffiths
14 Sept 2023 · Coroner Kate Robertson · North Wales East and Central
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. incomplete transfer of care
“The Investigation undertaken by the Health Board was deficient in that it did not contain pertinent points relating to how the transfer of care did not occur”
2. inadequate transfer documentation
“The Health Board's Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur”
3. paper based patient notes
“Patient notes for mental health are still not electronic; they are paper based”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequenily found to be inaccurate.”
This report
“The Health Board's Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur.”
Closely relatedConfidence 0.90 · high
This report
“The Health Board's Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur.”
Later report
“That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed”
Responses
2023-0333-Response-from-Betsi-Cadwaladr-University-Health-Board.pdf ↗· Betsi Cadwaladr University Health Board
Stated action · end of January 2024
“incidents. The Transfer and Discharge of Care Protocol has been revised to include explicit guidance relating to transfers of care between community teams. This includes the steps to be taken by the care coordinator, supporting administrative staff and the single point of access service (SPOA). Progression of this protocol through the Health Board ratification process is being led by the MH&LD Deputy Director of Nursing and progress is overseen by the MH&LD Policy and Procedure Group. The revised protocol”