Source · Prevention of Future Deaths
Jean Waghorn
Ref: 2019-0361
Date: 25 Oct 2019
Coroner: Veronica Hamilton-Deeley
Area: Brighton and Hove
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified concerns regarding unnecessary and inappropriate patient transfers between hospitals, noting that the Trust's transfer policy was effectively ignored. Additionally, previous Regulation 28 reports concerning the transfer policy had not led to changes, and new assessment tools were not used.
Date
25 Oct 2019
56-day deadline
3 Feb 2020 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
The coroner identified concerns regarding unnecessary and inappropriate patient transfers between hospitals, noting that the Trust's transfer policy was effectively ignored. Additionally, previous Regulation 28 reports concerning the transfer policy had not led to changes, and new assessment tools were not used.
View full coroner's concerns
(1) Unnecessary and inappropriate transfers between the Royal Sussex County Hospital, the Princes Royal Hospital and the Royal Sussex County Hospital.
(2) The Brighton and Sussex University Hospital NHS Trust policy for transfer was effectively ignored. (3) have made two recent previous regulation 28 reports concerning the Transfer Policy on 12 July 2018 and 20 July 2018. The response to the former included the assurance that a trust wide transfer policy working group was convened, led by three extra assessment tool sheets were created. None of these were used for Mrs Waghorn. Why not? What is the point of the Regulation reports if the trust ignores them?
(2) The Brighton and Sussex University Hospital NHS Trust policy for transfer was effectively ignored. (3) have made two recent previous regulation 28 reports concerning the Transfer Policy on 12 July 2018 and 20 July 2018. The response to the former included the assurance that a trust wide transfer policy working group was convened, led by three extra assessment tool sheets were created. None of these were used for Mrs Waghorn. Why not? What is the point of the Regulation reports if the trust ignores them?
Report sections
Investigation and inquest
On 1st July 2019 | commenced an investigation into the death of Jean Evelyn WAGHORN The investigation concluded at the end of the inquest on 15th October; 2019.The conclusion of the inquest was a Narrative Conclusion: - Mrs. WAGHORN died of pneumonia which developed when she was in hospital receiving conservative care for fractures to her neck sustained when she fell at home and hit her head on the floor: This lady was transferred between hospitals three times in just over 48 hours. FIND that the first transfer late on 23rd June 2019 (the of her fall) was appropriate she had been diagnosed with a fractured neck at Haywards Heath Local hospital and needed assessment and care at the South East Trauma and Spinal Centre in Brighton: FIND that the next two transfers were_not appropriate cannot say that they City City day
VERONICA HAMILTON-DEELEY DL,
VERONICA HAMILTON-DEELEY DL,
Circumstances of the death
Record of Inquest
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you AND your organisation have the power to take such action:
Copies sent to
See daysVERONICA HAMILTONDEELEY DL
Similar PFD reports
Report details
- Reference
- 2019-0361
- Date of report
- 25 October 2019
- Coroner
- Veronica Hamilton-Deeley
- Coroner area
- Brighton and Hove
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Feb 2020 (estimated from the Judiciary.uk publication date).
Sent to
- Brighton and Sussex University Hospital NHS Trust