Simon McAndrew
19 Feb 2014 · Coroner Dr R N Palmer · London (North)
A similar concern from this report was raised again 4 times later. See the linked reports.
The coroner's concerns
1. poor communication between NHS Trusts
“There are issues of poor communication which need to be addressed”
2. inability of patients to provide relevant information
“patients may not be able to provide the relevant, important information themselves”
3. misuse of separate computer databases
“use of different computer databases in Trusts and how they might better be managed”
4. lack of effective information access across NHS Trusts
“better method must surely be devised to ensure that key clinical staff can access important information held electronically in a different NHS Trust”
5. inadequate patient contact for distant residents
“better means must be devised of keeping in touch with the patient”
6. absence of structured care plans for high-risk patients
“formal, written care plan should be provided to the distant residential home”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“formal, written care plan should be provided to the distant residential home”
Later report
“The preparation of structured care plans for each patient.”
Closely relatedConfidence 0.80 · moderate
This report
“better method must surely be devised to ensure that key clinical staff can access important information held electronically in a different NHS Trust”
Later report
“The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be 'detrimental'”
Closely relatedConfidence 0.85 · high
This report
“There are issues of poor communication which need to be addressed. I acknowledge that even the most detailed communication in this instance may not have averted Mr McAndrews' actions and subsequent death.”
Later report
“SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT.”
Closely relatedConfidence 0.80 · moderate
This report
“There are issues of poor communication which need to be addressed.”
Later report
“relevant risk information was spread across multiple recording systems and was not always shared effectively between operational staff and clinical teams.”
Responses
No published response was found on judiciary.uk.