Source · Prevention of Future Deaths

Peter Patrick Adrian Barnes

Ref: 2013-0291 Date: 8 Nov 2013 Coroner: Neil Cameron Area: West Yorkshire (West) Responses identified: 0 / 1 View PDF

Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete or outdated data for care decisions.

Date 8 Nov 2013
56-day deadline 13 Feb 2014 est.
Responses identified 0 of 1
Mental Health related deaths

Coroner's concerns

AI summary
Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete or outdated data for care decisions.
View full coroner's concerns
(1) The hospital’s systems by which information about patients relating to matters which had been observed by nursing staff - including in particular information about serious incidents
- were communicated to the patients’ Responsible Clinician appeared to be inadequate to ensure that such information was full and/or accurate and/or up to date.

(2) The hospital’s systems by which decisions about patients’ care made by the Responsible

Similar PFD reports

Shared signals

Report details

Reference
2013-0291
Date of report
8 November 2013
Coroner
Neil Cameron
Coroner area
West Yorkshire (West)

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: 13 Feb 2014 (estimated).

Sent to

Cygnet Healthcare Ltd.

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