Stephanie Daniels
13 Dec 2013 · Coroner Nigel Meadows · Manchester City
A similar concern from this report was raised again 8 times later. See the linked reports.
The coroner's concerns
1. inadequate independent investigation of serious untoward incidents
“Internal NHS SUI Investigation v |ndependent Investigation”
2. insufficient clinical supervision of junior doctors
“Supervision of Junior Medical Staff”
3. unsafe medication prescribing by junior staff
“Prescribing of Medication by Junior Medical Staff”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care.”
Later report
“There was also evidence of an inadequate handover and preparation for the arrival of the premature baby with insufficient care plan details or consultation taking place.”
Identical hazardConfidence 0.90 · high
This report
“MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed”
Later report
“The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment.”
Closely relatedConfidence 0.90 · high
This report
“For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records.”
Later report
“Transfer and hand over of a patient to AMU from A & E. There was no clear hand over process and review when the deceased arrived on the AMU.”
Identical hazardConfidence 0.90 · high
This report
“For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records.”
Later report
“the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers”
Closely relatedConfidence 0.80 · moderate
This report
“it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen.”
Later report
“It is suggested that there was an absence of timely, full and accurate clinical record keeping by members of GMMH healthcare staff”
Closely relatedConfidence 0.90 · high
This report
“without appropriate audit and clinical/nursing leadership this may prove to be ineffective.”
Later report
“There was no robust audit system for checking compliance with the Trusts own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.”
Closely relatedConfidence 0.86 · high
This report
“| am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff. Two junior doctors were asked to attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication.”
Later report
“The inquest heard that due to the time of her arrival in the Emergency Department on 11th December 2020 consultants were not on site. The most senior doctors available were middle grade and the number available at that time of night was significantly reduced.”
Identical hazardConfidence 0.90 · high
This report
“MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed”
Later report
“Witnesses confirmed that no suitable bed was identified until approximately after 15:00 on 12 April 2022, which then became unavailable.”
Responses
2013-0353-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action
“I expect all healthcare professionals working in local Trusts to be fully trained and aware of the existing protocols in their local Trust. It is for local healthcare organisations to ensure that all staff are trained to the appropriate standard.”
2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups.pdf ↗· Manchester Clinical Commissioning Group
Stated action
“A revised governance process has been developed within the Citywide Commissioning, Quality and Safeguarding Team and the Trust now attends an established Citywide Patient Safety Committee. This committee meets monthly and is responsible for the review and monitoring of serious incidents requiring investigation reported by the Trust as well as any other patient safety related issues including those highlighted at inquest via Prevention of Future Death Reports.”
2013-0353-Response-by-Manchester-Mental-Health-NHS.pdf ↗· Greater Manchester Mental Health NHS Foundation Trust
Stated action
“the Trust will be reviewing the Serious Incident Requiring Investigation (SIRI) policy to consider the engagement of an independent investigator in complex cases.”