Sheila Johnson
19 May 2015 · Coroner Robert Hunter · Derby and Derbyshire
The coroner's concerns
1. investigation was perfunctory and slipshod
“The court was of the opinion that on this occasion there was insufficiency of inquiry and the investigation was perfunctory and slipshod”
2. no system for urgent recall of patients with potentially life threatening conditions
“The Trust appeared to have no system in place for the urgent recall of patients who had been discharged with potentially life threatening conditions”
3. future reports conducted in this manner may compromise patient clinical conditions and lead to deaths
“The court believes that should future reports be conducted in this manner then patient's clinical conditions may be compromised and such errors could lead to deaths in the future”
Responses
2015-0238-Response-by-Department-of-Health.pdf ↗· Tameside Hospital NHS Foundation Trust
Stated action
“that it will follow up any actions identified as a result of the Trust's response as part of its ongoing engagement with the Trust.”
2015-0238-Response-by-Tameside-Hospital-NHS-Trust.pdf ↗· Tameside Hospital NHS Foundation Trust
Stated action · 10 March 2015
“We have also introduced improvements to the process for internal review of serious incident reports. There is now an Executive led Serious Incident Review Panel which reviews all serious incident investigation reports and action plans and scrutinises and challenges them, providing feedback to the investigation teams when further clarity is required. The panel also require that responsible nursing and medical leads attend the meeting to feed back what changes have been made and what lessons have”