Toni Piel
9 Jul 2015 · Coroner Matthew Cox · Manchester (North)
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. discharged home without supervision
“At the time the deceased was discharged home following the head injury on 10 December 2014 the deceased's home circumstances were apparently not taken into account. Had such an assessment been made it would have been noted that there was no-one able to observe the deceased at home. The NICE clinical guideline 175 issued January 2014 recommends that this should be taken into account.”
2. lack of risk assessment documentation
“No assessment of the risk factors in discharging the deceased was documented in the deceased's records.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“No assessment of the risk factors in discharging the deceased was documented in the deceased's records.”
Later report
“In this case, critical risk assessments had not been updated and/or completed (falls, cot sides etc.) There were missed opportunities to re-assess.”
Closely relatedConfidence 0.80 · moderate
This report
“No assessment of the risk factors in discharging the deceased was documented in the deceased's records.”
Later report
“That the information provided by the Royal Oldham Hospital to the Home on 10 October 2018 was inaccurate in suggesting that Mrs [name redacted] was able to mobilise.”
Responses
2015-0263-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care