Source · Prevention of Future Deaths
Lillian Robinson
Ref: 2014-0041
Date: 26 Jan 2014
Coroner: Martin Flemimg
Area: Surrey
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified a lack of communication between the hospital and home regarding mental capacity assessments, and unqualified medical carers evaluating patient capacity. Concerns were also raised about poor note-taking and continuity of patient care records.
Date
26 Jan 2014
56-day deadline
23 Mar 2014 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner identified a lack of communication between the hospital and home regarding mental capacity assessments, and unqualified medical carers evaluating patient capacity. Concerns were also raised about poor note-taking and continuity of patient care records.
View full coroner's concerns
During the course of the inquest the evidence revealed a matter that gave rise to concern and which, in my opinion, there is a risk that future deaths could occur by reason thereof unless action is taken.
The MATTER OF CONCERN is as follows. –
RT3848 RT3848 Lack of communication between hospital and home re mental capacity assessment Unqualified medical carers evaluating the appropriateness of capacity in patients with mild/moderate dementia Poor note taking and continuity of patient care notes
At the inquest I heard very helpful evidence from I would be obliged if you could confirm that steps have been taken to address these concerns.
The MATTER OF CONCERN is as follows. –
RT3848 RT3848 Lack of communication between hospital and home re mental capacity assessment Unqualified medical carers evaluating the appropriateness of capacity in patients with mild/moderate dementia Poor note taking and continuity of patient care notes
At the inquest I heard very helpful evidence from I would be obliged if you could confirm that steps have been taken to address these concerns.
Report sections
Investigation and inquest
On 22/1/13 I opened an inquest into the death of Lillian Rose Robinson who, at the date of her death was aged 89 years. The inquest was resumed and concluded on 15th and 16th January 2014. I found that the cause of death to be: ‐ 1a. Bronchopneumonia I concluded with a Narrative finding
Circumstances of the death
On 31/10/12, Lillian Rose Robinson was admitted to Brockhurst Care Home for intermediary care. On 27/10/12 she was transferred to Upper Halliford nursing home where she was found to have deteriorated and she succumbed and died from bronchopneumonia on 28/12/12.
Copies sent to
I have sent a copy of this report toChief CoronerCoroners Society for England and Wales DATED this 26th January 2014
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Report details
- Reference
- 2014-0041
- Date of report
- 26 January 2014
- Coroner
- Martin Flemimg
- Coroner area
- Surrey
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: 23 Mar 2014 (estimated from the report date).
Sent to
- Surrey County Council