William Nichols
18 Aug 2023 · Coroner Leila Benyounes · Gateshead and South Tyneside
The coroner's concerns
1. inconsistent understanding of post-discharge procedures and access points
“Inconsistency in understanding between the hospital and the community teams as to the procedure to follow post discharge from vascular surgery and the points of access in the event of concern or complication (including suspected infection, or bleeding)”
2. lack of documented patient advice on discharge access points
“The absence of provision of documented advice to patients on discharge as to points of access in the event of concern or complication (including suspected infection or bleeding)”
3. poor communication of post-operative bleeding concerns
“Poor communication from the vascular ward when concerns were raised post- operatively, particularly the concern about bleeding in the wound discharge”
4. inconsistent clinical assessment documentation
“Poor record keeping from the community team which meant that key clinical assessment information was not consistently recorded”