Source · Prevention of Future Deaths
Gillian Crossley
Ref: 2014-0394
Date: 4 Sep 2014
Coroner: Catherine Mason
Area: Leicester City & South Leicestershire
Responses identified: 0 / 1
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Inadequate documentation, insufficient patient observation and monitoring, poor discharge planning, and a breakdown in communication between care providers were identified.
Date
4 Sep 2014
56-day deadline
30 Oct 2014 est.
Responses identified
0 of 1
Coroner's concerns
Inadequate documentation, insufficient patient observation and monitoring, poor discharge planning, and a breakdown in communication between care providers were identified.
View full coroner's concerns
_ have received previous assurances from the University Hospitals Leicester that measures have been in place to audit documentation s0 that it meets professional standards. However; found the following during this inquiry: Inadequate documentation Failure to observe and monitor in accordance with Mrs Crossley s needs to properly assess the fitness for discharge and properly plan that discharge Inadequate communication between those who were responsible for the care treatment of Mrs Crossley
Report sections
Investigation and inquest
On 2ha April 2013 commenced an investigation into the death of Gillian Crossley aged 76 years The investigation concluded at the end of the inquest on 29"h August 2014. The conclusion of the inquest was that there were failings in her care and she was discharged home when she should not have been: result there was missed opportunity to detect her deteriorating condition sooner. However, because the mechanism for the insult to the bowel was unknown, it was also unknown if the outcome would have been different
Circumstances of the death
Mrs Crossley underwent elective bowel surgery on the 18" March 2013. The surgery was technically successful but her recovery period was slower than expected and she was discharged home on the 26" March 2013 but re-admitted the following extremis as a result of bowel necrosis and subsequent perforation: Despite further surgical intervention she remained gravely iIl and died on the 28" March 2013.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
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Report details
- Reference
- 2014-0394
- Date of report
- 4 September 2014
- Coroner
- Catherine Mason
- Coroner area
- Leicester City & South Leicestershire
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: 30 Oct 2014 (estimated).
Sent to
- University Hospitals Leicester