Veronica Gregory
6 Dec 2018 · Coroner Nigel Meadows · Manchester (City)
The coroner's concerns
1. inadequate care plans and risk assessments
“Inadequate and insufficient care plans including specific risk issues together with, a lack of appropriate review and reassessment either following an incident or as a matter or general practise.”
2. incomplete daily observation records
“A failure to have appropriate daily observation records fully completed.”
3. inadequate clinical records and guideline compliance
“A failure to ensure that full and appropriate clinical records of any physical examination and action taken as a result being made. In addition, failure to refer to appropriate NICE Guidelines and comply with them.”
4. failure to follow medical assistance protocols
“A failure to ensure that agreed protocols for seeking specific medical help and assistance were followed in respect of specific incidents.”
5. insufficiently trained staff
“A failure to ensure sufficient numbers of adequately trained staff at all times.”
6. inadequate supervision and governance
“A failure to ensure adequate supervision and governance of all relevant staff”