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 View PDF

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
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
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.

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.
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

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