Source · Prevention of Future Deaths

Geoffrey Ellis

Ref: 2016-0186 Date: 13 May 2016 Coroner: Andrew Bridgman Area: Manchester South Responses identified: 1 / 1 View PDF

Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care pathways.

Date 13 May 2016

56-day deadline 8 Jul 2016

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care pathways.

View full coroner's concerns

_ Illegible clinical records andlor a failure to complete important documents creates serious risk of a breakdown in communication and misinformation within a patients care pathway:

Responses

1 respondent

Stockport NHS Trust NHS / Health Body

8 Aug 2016 PDF

Action Planned

Stockport NHS Trust is installing an electronic patient record system (EPR) called 'TrakCare' with full roll out expected in 2017. In the meantime they will continue monthly 'live' spot audits of inpatient records to improve written records and communication. (AI summary)

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Dear Mr Bridgman, Re: Geoffrey ELLIS (Deceased) Thank you for your letter, of 19 July 2016, concerning the inquest of the above named patient: As always, am grateful to you for highlighting your concerns on the Regulation 28 'Report to prevent future deaths' and for providing me with an opportunity to respond. Your concerns are as follows Illegible clinical records and or a failure to complete important documents, creates a serious risk of a breakdown in communication and misinformation within a patients' care pathway: The Trust is currently in the process of installing an electronic patient record system (EPR); this is computerised version of the entire healthcare record. Instead of hospital staff using a mixture of paper electronic records, information will be available to them online in one place. We already use a variety of electronic systems to help staff look after our patients but EPR will bring all this information about our patients together into one system for better and safer care: The Trust"$ electronic patient record system is being supplied by InterSystems, a global software company and the system is called 'TrakCare'_ interSystems supply EPR systems to 463 hospitals in 25 countries worldwide: This system will improve patient safety and outcomes by standardising pathways underpinned by best practice, resulting in an informed workforce supported by comprehensive patient information at their fingertips_ It will remove issues relating to the illegibility of written records and will also assist with the completion of important documents , as the system will employ 'force function' , meaning the record cannot be left incomplete_ The roll out for the system will be completed in 2017 . In the meantime we will continue to endeavour t0 improve written records and communication by undertaking monthly 'live' spot audits, of 30 records per audit; relating to inpatients on our wards. hope that this response answers your concerns and provides you with the assurance that the Trust is committed to improving the quality of care we give to all our patients_ Please do not hesitate to contact me if you have any Turther questions regarding this matter: Yours singerely, Inn Bames Chief Executive Your Health: Our Priority: and the

Report sections

Investigation and inquest

On 14mh September 2015 an investigation was commenced into the death of Geoffrey Ellis who died while an in-patient at Stepping Hill Hospital on 8th September 2015. The investigation concluded with an Inquest held on 12t January 2016 and 24t April 2016. The conclusion of the Inquest was: Misadventure contributed to by neglect Medical cause of death la Aspiration pneumonia Vomiting secondary to Pseudo-Obstruction of Small Bowel Recent Laparoscopic Nephroureterectomy for Kidney Tumour Chronic Peritoneal Adhesions Coronary Artery Atheroma, Hypertension

Circumstances of the death

On 3 September 2015 Geoffrey Ellis was admitted to the Department;, Stepping Hill Hospital the Consultant Care ofl Consultant Urologist. Geoffrey Ellis was to undergo a left side laparoscopic nephro-uterectomy, removal of kidney and ureter: The operation was carried out on 3r September 2015 and to all intents was uneventful and a success albeit that it was necessary to complete the operation by means of open laparotomy: Geoffrey Ellis was admitted to Ward C6 that found that a failure to exam Geoffrey Ellis' abdomen and to detect distension, on and from 6th September 2015 and to treat hiccups possibly present for 24 hours but in any event present from the morning of 7h September until the late evening contributed either in combination or singularly, to Geoffrey Ellis' death on the morning of 8" September 2015. and Urology evening:

Action should be taken

In my opinion action should be taken to develop a system, and to ensure its operation, to monitor clinical records and to identify and eradicate illegible record keeping and to identify and eradicate failures to complete important clinical records_

Similar PFD reports

Shared signals

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Report details

Reference: 2016-0186
Date of report: 13 May 2016
Coroner: Andrew Bridgman
Coroner area: Manchester South

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Jul 2016.

Sent to

Stockport NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.