Source · Prevention of Future Deaths
Charles Bradley
Ref: 2014-0118
Date: 17 Mar 2014
Coroner: Andre Rebello
Area: Liverpool
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted inadequate and ineffective record-keeping and communications at Arrowe Park Hospital, evidenced by issues with patient transfer information and inconsistent documentation of a patient's fall.
Date
17 Mar 2014
56-day deadline
12 May 2014 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner noted inadequate and ineffective record-keeping and communications at Arrowe Park Hospital, evidenced by issues with patient transfer information and inconsistent documentation of a patient's fall.
View full coroner's concerns
To the day:
During the investigation and inquest into Mr Bradley's death it was found that the record-keeping and communications at Arrowe Park Hospital were inadequate, ineffective making them unsafe. This was evidenced by findings that though Leeds Teaching Hospital had effective records as to the arrangements for the transfer of Mr Bradley to Arrowe Park on the 21st February 2013, when Mr Bradley arrived at Arrowe Park they were not expecting him: This is likely to have caused added worry and stress to his rehabilitation plan. It is further evidenced by the inadequate recording of his fall on the 215 February 2013. From evidence it was unclear as to whether it was witnessed or not; was it in a bathroom and if s0 why was there mention of a filing cabinet near where he lay? In other cases the matters reported could result in fatalities. Documentation; recordkeeping and communications are core basic skills for all who work In healthcare_ Neither the HEALTH aspect nor the CARE aspect of a health care service can be delivered without these basic skills. It would be helpful to see a cross Trust action plan with regard to the improving documentation, record-keeping and communication in the response to this report
During the investigation and inquest into Mr Bradley's death it was found that the record-keeping and communications at Arrowe Park Hospital were inadequate, ineffective making them unsafe. This was evidenced by findings that though Leeds Teaching Hospital had effective records as to the arrangements for the transfer of Mr Bradley to Arrowe Park on the 21st February 2013, when Mr Bradley arrived at Arrowe Park they were not expecting him: This is likely to have caused added worry and stress to his rehabilitation plan. It is further evidenced by the inadequate recording of his fall on the 215 February 2013. From evidence it was unclear as to whether it was witnessed or not; was it in a bathroom and if s0 why was there mention of a filing cabinet near where he lay? In other cases the matters reported could result in fatalities. Documentation; recordkeeping and communications are core basic skills for all who work In healthcare_ Neither the HEALTH aspect nor the CARE aspect of a health care service can be delivered without these basic skills. It would be helpful to see a cross Trust action plan with regard to the improving documentation, record-keeping and communication in the response to this report
Report sections
Investigation and inquest
On 5'h March 2013 an investigation commenced into death of Charles Gavin BRADLEY , Aged 73. The investigation concluded at the end of the inquest on 3rd March 2014. The conclusion of the inquest was Ia Subdural Haematoma Accidental death
Circumstances of the death
On Thursday 21st February 2013, Charles Gavin Bradley fell in an unwitnessed fall in the Assessment Unit at Arrowe Park Hospital, at about 18.00, sustaining head injuries which proved fatal. He had been transferred from Leeds Teaching Hospital to Arrowe Park Hospital the same There had been some confusion in the Primary Care Trust in Leeds in that no wheelchair was provided for the transfer When he arrived at Arrowe Park Hospital; in spite of a communication from the bed manager at Arrowe Park Hospital delaying his transfer for a day, to 21st February 2013, there wes:no bed available at Arrowe Park Hospital.
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_ YouR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by 12th May 2014_ 6, 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:
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Report details
- Reference
- 2014-0118
- Date of report
- 17 March 2014
- Coroner
- Andre Rebello
- Coroner area
- Liverpool
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: 12 May 2014 (estimated from the report date).
Sent to
- Arrowe Park Hospital