Thelma Jones
12 Aug 2015 · Coroner Veronica Hamilton-Deeley · Brighton and Hove
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of coordinated care planning
“very little evidence of any joined up thinking with regard to her care or to plans, either for her future treatment or for her future placement, or for discharge whilst in AMU”
2. incomplete National Early Warning System scoring
“after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23 February 2015, the scoring is not completed”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with the Nursing Home who were expected to receive him back or with [the deceased]' son.”
This report
“* firstly the fact that there was very little evidence of any joined up thinking with regard to her care or to plans, either for her future treatment or for her future placement, or for discharge whilst in AMU”
Closely relatedConfidence 0.85 · high
This report
“after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23 February 2015, the scoring is not completed”
Later report
“there were missed opportunities to escalate Mrs [name redacted] treatment arising from raised NEWS scores where there was no report of those raised scores either to the doctors on the ward or to the critical care outreach team”
Identical hazardConfidence 0.92 · high
This report
“after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23 February 2015, the scoring is not completed.”
Later report
“(1) Once again | must write concerning the serious failings in the use of NEWS. Please see the Record of Inquest for details.”
Responses
2015-0318-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust.pdf ↗· Brighton and Sussex University Hospitals NHS Trust
Stated action · 7 November 2015
“We have carried out a careful review of the medical records with the appropriate personnel.”