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Kevin McDonald

Ref: 2019-0156 Date: 16 May 2019 Coroner: Geraint Williams Area: Worcestershire Responses identified: 0 / 1 View PDF

Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge care and increasing risks.

Date 16 May 2019
56-day deadline 11 Jul 2019
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge care and increasing risks.
View full coroner's concerns
(1) During the inquest the clinician giving evidence indicated that the discharge paperwork from the clinical decision-making unit is different to that from other wardsldepartments and it is not clear what a follow-up or advicelguidance is given to patients_ The family of the deceased contend that there was no advice or follow-up and that the deceased was left not knowing what to do about his increasing It appears that no documentation has been found within the hospital about this The standardisation of discharge documentation would appear to be in need of review and invite you to consider this: doing pain

Report sections

Investigation and inquest
On 31st of January 2019 commenced an investigation into the death of Kevin John McDonald then aged 53 years The investigation concluded at the end of the inquest on 16th of May 2019. The conclusion of the inquest was A case of suicide the medical cause of death being Exsanguination caused by multiple incised wounds
Circumstances of the death
Mr McDonald was admitted into the Alexandra Hospital in Redditch following a spinal injury where he was assessed and quickly discharged with analgesia but apparently no follow-up. He later killed himself leaving a note indicating that he was so because he could no longer stand the pain
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.

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Post Office Horizon Inquiry Close HSS Dispute Resolution Procedure when HSSA opens COVID-19 Inquiry Proportionate Access to Linked Healthcare Records Muckamore Abbey Inquiry Consultation before patient transfers Muckamore Abbey Inquiry Named person approval for transfers Muckamore Abbey Inquiry Independent living skills focus Muckamore Abbey Inquiry Higher-funded resettlement team for complex needs Muckamore Abbey Inquiry Time frame and financial information for families Muckamore Abbey Inquiry Continuing community support provision Muckamore Abbey Inquiry Key individual for resettlement communication Fuller Inquiry Postgraduate training governance clarity

Report details

Reference
2019-0156
Date of report
16 May 2019
Coroner
Geraint Williams
Coroner area
Worcestershire

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: 11 Jul 2019.

Sent to

Worcestershire Acute Hospital NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.