Source · Prevention of Future Deaths
John Malone
Ref: 2014-0026
Date: 21 Jan 2014
Coroner: John Pollard
Area: Manchester (South)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe hospital discharge letter sent to the GP lacked vital information, including admission and discharge details, potentially contributing to a patient's fall and subsequent subdural haemorrhage shortly after discharge.
Date
21 Jan 2014
56-day deadline
18 Mar 2014 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The hospital discharge letter sent to the GP lacked vital information, including admission and discharge details, potentially contributing to a patient's fall and subsequent subdural haemorrhage shortly after discharge.
View full coroner's concerns
took evidence from the two GP's caring for the deceased and they showed to me; inter alia , a discharge letter from your hospital dated 21"' October 2013 a copy of which append hereto. You will note that this document is woefully short on detail and has significant omissions of vital information for the GP's. On page one of the report there are no details given as to Admission date, admission ward, admission method, admission source, discharge destination or discharge date. patient sustained a fall within 3 days of his discharge and this led to or exacerbated his subdural haemorrhage.
Report sections
Investigation and inquest
On 29th October 2013 commenced an investigation into the death of John Joseph Malone dob 16"h January 1932, The investigation concluded at the end of the inquest on 8" January 2014. The conclusion of the inquest was that Mr Malone suffered two falls at his home address; the first several weeks before his death and the second on the 24" October 2013 which led to his sustaining a subdural Haematoma and concluded that he had died an accidental death
Circumstances of the death
As paragraph 3 above
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: It is essential that full information is passed promptly to the GP practice of a patient discharged.
Similar PFD reports
Report details
- Reference
- 2014-0026
- Date of report
- 21 January 2014
- Coroner
- John Pollard
- Coroner area
- Manchester (South)
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: 18 Mar 2014 (estimated from the report date).
Sent to
- Tameside Hospital NHS Foundation Trust