Terence Stilges
30 Jun 2016 · Coroner Louise Hunt · Birmingham and Solihull
The coroner's concerns
1. patient discharged before troponin result available
“A discharge summary was prepared several days in advance for this patient. This summary did not mention the need for a further troponin result before the patient was discharged home. In addition the medical records wrongly specified that he should be discharged home. Therefore the patient was incorrectly sent home before the second troponin result was available.”
2. discharge summaries prepared before test results
“heard that there was a practice of writing discharge summaries in advance despite tests results being outstanding”
3. other patients discharged before tests complete
“could result in other patients being discharged before their tests are complete”
Responses
2016-0293-Response-by-NHS-England.pdf ↗· Heart of England NHS Trust
Stated action
“e they are in the process of reviewing the electronic systems to ensure robustness; e they have a comprehensive training programme in place to ensure that junior doctors are aware of the discharge process; e the individual clinicians involved have been asked to review this significant event in their annual appraisal; and e the event will form part of their internal quality improvement process - the Bisny Business Forum", to ensure that all learning is understood by clinicians”