Source · Prevention of Future Deaths

Margaret Ferry

Ref: 2015-0450 Date: 23 Oct 2015 Coroner: Karin Welsh Area: Sunderland Responses identified: 1 / 1 View PDF

The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and misunderstandings during patient referrals.

Date 23 Oct 2015
56-day deadline 18 Dec 2015 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and misunderstandings during patient referrals.
View full coroner's concerns
In the circumstances it is my statutory to report t0 you: Evidence was given at the Inquest that there was no policy in place between Hospitals Sunderland NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust clarifying the areas of responsibility and channels of communication between the two when patients are referred. 2_ Evidence was given that there were poor levels of communication both direct and indirect between medical professionals at each trust and poor understanding of each other differing practices and procedures_ ACTION SHOULD BE TAKEN In my opinion action should be taken t0 prevent future deaths and believe you have the power t0 take such action. YOUR RESPONSE You are under a to respond to this report within 56 of the date of this report. namely by 1Sth December 2015_ [, the coroner, may extend the period. Your response must contain details of action taken Or proposed to be taken; setting out the timetable for action Otherwise YOU must explain why no action_is proposed COPIES and PUBLICATION Thave sent a copy of my report to the Chief Coroner and to the following Interested Persons: County Durham and Darlington NHS Foundation Trust and their Solicitors and Counsel Family CQC am also under a to send the Chief Coroner a copy of your response The Chief Coroner may publish either or both in a complete or redacted or summary form . He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me; the coroner; at the time of your response_about the release o the publication of your response by the Chief Coroner: Dated this of October 2015 Signature Iou Assistant Coroner for the City of Sunderland May duty City duty days duty 2354 day

Responses

1 respondent
Response
17 Dec 2015 PDF
Action Taken

A new standing operational procedure has been developed to provide a comprehensive approach to inter-organisational referrals for plastic surgery opinions; it ensures that the referral is clearly documented, a suitable response is provided within clearly defined timescales, and it is clear to all parties that patients on wards at Sunderland Royal remain under the care of the admitting consultant at all times, and not the plastics team. (AI summary)

View full response
Dear Karin

Please see the response from the Trust, County Durham and Darlington Foundation Trust, detailing the actions that have been taken following the concerns that you raised after the inquest held for the late Mrs Margaret Anne Kelly.

In your correspondence you raised two main issues of concern:-

1. Evidence was given at the Inquest that there was no policy in place between City Hospitals Sunderland NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust clarifying the areas of responsibility and channels of communication between the two when patients are referred.

2. Evidence was given that there were poor levels of communication both direct and indirect between medical and professionals at each trust and poor understanding of each other’s differing practices and procedures.

We have recognised that there were significant gaps in the provision of services to Margaret therefore, Anne Ferry, City Hospitals Sunderland, and the Trust have worked closely with our colleagues at City Hospital Sunderland to address the issues raised. In collaboration we have developed a new standing operational procedure to provide a comprehensive approach to inter organisational referrals for plastic surgery opinions. The standard operating procedure provides a process to ensure that the referral is clearly documented; that a suitable response is provided within clearly defined timescales, and that it is clear to all parties that patients on wards at Sunderland Royal remain under the care of the admitting consultant at all times, and not the plastics team. I have included this for your information.

Chief Executive. Darlington Memorial Hospital, Hollyhurst Road, Darlington, County Durham DL3 6HX Please don’t hesitate to contact me if you require any further on this issue

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Report details

Reference
2015-0450
Date of report
23 October 2015
Coroner
Karin Welsh
Coroner area
Sunderland

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: 18 Dec 2015 (estimated).

Sent to

City Hospitals Sunderland NHS Foundation Trust

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