Robert Fuller
2 Apr 2024 · Coroner Sarah Slater · South Yorkshire East
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate documentation of patient behaviour and assessments
“There was evidence of poor record keeping on the ward. This included behaviour charts, enhanced patient supervision records and daily evaluation charts not being consistently recorded. There was either no or poor documentation of other professionals entering the ward and evaluating patients, and the outcome of such assessments not being recorded. Some of the documentation was also described as not fit for purpose within the frailty unit due to the needs of the patients. This insufficient record”
Linked reports
Closely relatedConfidence 0.92 · high
Earlier report
“During the course of the evidence it became clear that the poor quality nursing notes and the lack of information of the observation chart made it difficult for the reviewing Consultants to get a clear picture of events that had been occurring.”
This report
“There was evidence of poor record keeping on the ward. This included behaviour charts, enhanced patient supervision records and daily evaluation charts not being consistently recorded.”
Closely relatedConfidence 0.86 · high
This report
“There was evidence of poor record keeping on the ward. This included behaviour charts, enhanced patient supervision records and daily evaluation charts not being consistently recorded.”
Later report
“Poor documentation, Communication, and systems- There were no clear communication, documentation, or systems in place, to identify if investigations had been performed as requested.”
Responses
2024-0179-Response-from-DBTH.pdf ↗· Doncaster Royal Infirmary
Stated action · coming weeks
“We have taken the opportunity to review and refine our Enhanced Care Policy and this is proceeding through our governance process for sign off over the coming weeks. One of the changes has been to separate our Falls Risk Assessment and Confusion Risk Assessment to support easier recognition of patients who are either a falls risk or those patients who need a designated level of supervision due to behaviours of concern.”