Source · Prevention of Future Deaths

Winifred Dennis

Ref: 2014-0167 Date: 14 Apr 2014 Coroner: Rebecca Cobb Area: Kent (North-East) Responses identified: 1 / 1 View PDF

Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new care homes.

Date 14 Apr 2014

56-day deadline 9 Jun 2014 est.

Responses identified 1 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new care homes.

View full coroner's concerns

_ (1) The evidence was that within Kent Community Health NHS Trust the community nurses are organised into teams dependent upon the GP surgeries that they are covering: As a result; the moving of a patient from her own home to a Care Home, or between Care Homes; can cause her to be transferred from one Community Nursing Team to another, as occurred in this instance_ Although the patient's notes would transfer;the Trust had no formal handover document as such for a patient_in these The sitting The circumstances and, in this instance, the information that at her previous Home she had had the benefit of an airflow mattress was not communicated to the next Home on her move there. Care Homes look to the community nurses for such guidance (2) In other cases, similar important information not directly of a clinical nature might not be transferred and the chances of optimum care being delivered to a patient might accordingly be reduced_

Responses

1 respondent

Kent Community Health NHS Trust NHS / Health Body

6 Jun 2014 PDF

Action Taken

Kent Community Health NHS Trust has devised a formal process for transfer of care between community nursing teams. A working group has been established to revise policies and procedures, improve documentation and monitor through clinical audit. The training available to staff for holistic assessment and care planning has been revised and is being rolled out. (AI summary)

View full response

Dear Ma'am Resumed Inquest touching the death of Winifred Olive Dennis write further to your correspondence dated 14 April 2014, which encloses a copy of the Regulation 28 letter Firstly, would to take the opportunity to thank you for bringing this matter to my attention. have conducted a full internal review of the care afforded to Ms Dennis by the Community Nursing Teams across Kent Community Health Care Trust: can confirm that as a result of the investigation, an action plan has been implemented into practice, to target and address your concerns. Concerns Raised These concerns were in relation to the lack of a formal handover process between our Community Nursing Teams The Trust recognises that structured handover processes are vital in order to deliver a co-ordinated level of care that meets patient's on-going needs in the community. Response A formal process to enable the transfer of care between community nursing teams has been devised: A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care_ Work is already underway to improve the documentation associated with transfer to ensure all patients a full holistic reassessment to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care_ This process ensures continuity of care_ Patients' on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to stafffor holistic assessment and care planning has been revised and the new programme is now being rolled out am confident that this will enable our Community Nursing Teams to deliver a high level of quality care, which is patient focussed: prior have

2 The implementation of these actions will be regularly monitored through the Trust's committee structures. The Trust will be making contact with the family of Ms Dennis, to go through the details of our internal investigation. am grateful for the opportunity to review and improve our service and thank you once again for highlighting these issues to me

Report sections

Investigation and inquest

On 25th July 2013, commenced an investigation into the death of Winifred Olive DENNIS, The investigation concluded at the end of the inquest on 22nd January 2014_ The conclusion of the inquest was a Narrative (as set out in box 4 below), the clinical cause of death being: 1a. Bronchopneumonia, Deep sacral pressure sore_ Coronary atheroma, Diabetes mellitus.

Circumstances of the death

Mrs. DENNIS died on 27th December 2012 at her home address of St Alban's House, Grove, Deal, Kent following a slow deterioration in her health leading to reduced _ and ultimately no, mobility. The sacral pressure sore started on around 1gh September 2012, initiated by a scratch as a result of an infection she was suffering from During her time at St Alban'S, from the end of July 21012 up to the time of her death, she was regularly seen by community nurses, podiatrists and general practitioners and had a pressure-relieving mattress, an air cushion for on and, from early September, heel protectors, but not an airflow mattress that she had had at the previous Home No indication was given by anyone to the Residential Home that such a mattress would be appropriate, until December when she was too poorly to be moved:

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.

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Shared signals

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Report details

Reference: 2014-0167
Date of report: 14 April 2014
Coroner: Rebecca Cobb
Coroner area: Kent (North-East)

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: 9 Jun 2014 (estimated).

Sent to

Kent Community Health NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.