Sean Owen
23 Oct 2020 · Coroner Catherine McKenna · Manchester North
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of quality assurance for discharge summary letters
“there is currently no system in place at Pennine Care NHS Foundation Trust for quality assurance of the Discharge Summary Letters which are sent to General Practitioners when a patient is discharged from in-patient care”
2. inadequate review of discharge letter by senior clinician
“Discharge Letter that was sent to Mr [name redacted] GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician”
3. misrepresentation of patient's clinical history in discharge letter
“It omitted references to the overdoses and was erroneous in stating that there had been 'no issues or incidents' during the admission; that the Deceased 'never showed any DSH behaviour as an inpatient' and that 'we did not see any SH behaviour or expressed thought from [the deceased] during his admission.'”
4. failure to communicate risk of medication non-compliance
“made no reference to the significant risk associated with non-compliance”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“There is no policy in existence within the Trust to address the process of patient medication monitoring/compliance and the triangulation of corroborative information, particularly within the community setting.”
This report
“The Discharge Letter that was sent to Mr [name redacted] GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician.”
Closely relatedConfidence 0.80 · moderate
This report
“The Discharge Letter that was sent to Mr [name redacted] GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician.”
Later report
“A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.”
Responses
2020-0215-Response-from-Pennine-Care-NHS-Foundation-Trust-Redacted.pdf ↗· Pennine Care NHS Trust
Stated action
“The Clinical Director for the Borough has established process that ensures: - All new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries. - During their first month working on the wards all new trainees have their written admission/discharge summaries checked and discussed at the ward round held prior to discharge of the patient. A senior doctor checks the documentation.”