Source · Prevention of Future Deaths
Leslie Lerner
Ref: 2016-0487
Date: 28 Oct 2016
Coroner: Veronica Hamilton-Deeley
Area: Brighton and Hove
Responses identified: 0 / 1
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Inadequate junior doctor training in sling application, lack of senior doctor review for high-risk patients, and failure to follow hospital discharge protocols for senior review and analgesia.
Date
28 Oct 2016
56-day deadline
7 May 2017 est.
Responses identified
0 of 1
Coroner's concerns
Inadequate junior doctor training in sling application, lack of senior doctor review for high-risk patients, and failure to follow hospital discharge protocols for senior review and analgesia.
View full coroner's concerns
13th 2016 (1) Junior Doctor applied wrong sling with wrong knot for Mr Lerner after she had learned that he had had fractured shoulder which was to be treated conservatively. heard that a Nurse should have applied the sling because the chances are that he or she would have known which sling to use and how to apply it (2) Although the Junior Doctor discussed Mr Lerner with her Senior; the Senior did not actually see him nor specifically state which type of sling (should have been a collar and cuff) should be was told that the Senior should always see the Patient: 14th May 2016 (1) Mr Lerner was kept in the Royal Sussex County Hospital overnight and towards the middle of the he was discharged without a Senior Review. was told that before he was discharged he should have been seen by a Senior Doctor and it may well have been that the inappropriately applied sling would have been recognised. He was sent home with no analgesia. He should have been given analgesia It became clear from the evidence that the pain that he suffered was very much part of his overall deterioration and an exacerbating factor with his dementia The Hospital's own Discharge Protocol was not followed, it should have been_ Hove May applied. day
VERONICA HAMILTON-DEELEY, LLB.
VERONICA HAMILTON-DEELEY, LLB.
Report sections
Investigation and inquest
On 7th June, 2016 commenced an investigation into the death of Leslie Isaac LERNER: The investigation concluded at the end of the inquest on 18th Octobar, 2016.The conclusion of the inquest was NARRATIVE CONCLUSION:
Circumstances of the death
See Record of Inquest
VERONICA HAMILTON-DEELEY, LLB.
VERONICA HAMILTON-DEELEY, LLB.
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
VERONICA HAMILTONDEELEY, LLB_
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Report details
- Reference
- 2016-0487
- Date of report
- 28 October 2016
- 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: 7 May 2017 (estimated).
Sent to
- Brighton and Sussex University Hospitals NHS Trust