Sebastian Daniels
22 Sept 2023 · Coroner Robert Simpson · Hampshire, Portsmouth and Southampton
The coroner's concerns
1. abnormal triglyceride levels not escalated
“The abnormal triglyceride levels in Mr [name redacted] blood, whilst reported by the lab, were not escalated by telephone as this was not required by the hospital procedure at the time”
2. discharge summary format unclear for GP actions
“The RCA report identifed that the format of discharge summaries provided to GPs by the ED department needed to be reviewed to ensure that actions to be undertaken by GPs were clearly identified.”
3. annual physical health check blood tests not taken by Southern Health
“In relation to the blood tests required under the clozapine guidelines I was informed that Southern Health take the monthly blood tests and run these in the clozapine clinic. However the blood tests required of the annual physical health checks are not taken by the Southern Health staff but rather patients are required to attend phlebotomy services elsewhere for the blood to be taken”
Responses
2023-0346-Response-from-Hampshire-Hospitals-NHS-Foundation-Trust.pdf ↗· Hampshire Hospitals NHS Foundation Trust
2023-0346-Response-from-Southern-Health-NHS-Foundation-Trust.pdf ↗· Southern Health NHS Foundation Trust
Stated action · early adopter operationalisation
“The Trust is pleased to report that whilst the challenges described to you at inquest remain, the consensus view from the meetings that took place was that our aspiration should very much be to seek to overcome these obstacles such as to be able to introduce the changes that you have suggested.”