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
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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patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete or outdated data for care decisions.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
Coroner's concerns
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patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete or outdated data for care decisions.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 Clinician were communicated to nursing staff appeared not to have operated properly and accordingly may be inadequate to ensure that such information about such decisions is communicated in an appropriate and/or timely manner.
(3) There appeared to be no system of checking upon or auditing the systems referred to at paragraphs (1) and (2) above to ensure that the Responsible Clinician was receiving full, accurate and up to date information and that nursing staff were receiving appropriate and timely information about the Responsible Clinician’s decisions.
(4) There appeared to be no system to ensure that members of patients’ families were invited to be involved in the process by which decisions are made about their care, notwithstanding that they may often be able to impart useful information based upon the patient’s past behaviour, potentially including information about particular matters which might increase or decrease the risk of harm to or self-harm by such patients.
(5) The hospital’s procedure for responding to patients being absent without leave included reporting such patients to the police as missing persons, but did not appear to be adequate to ensure that members of staff so reporting, or thereafter giving further information, to the police had access to all of the information about the patient which was likely to be required by the police for the purpose of their enquiries.
6. Action Should be Taken In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action.
7. Your Response You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 January 2013. I, the coroner, may extend the period, and do hereby so extend it (in the light of the forthcoming Christmas vacation) to 18 January 2014.
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.
8. Copies and Publication I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
Continued/………
-3-
8 November 2013
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
9. Date: 8 November 2013
Yours sincerely,
Signed on behalf of N. A. Cameron Assistant Coroner By T. H. Ratcliffe, Assistant Coroner
Cc The Chief Coroner
- 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 Clinician were communicated to nursing staff appeared not to have operated properly and accordingly may be inadequate to ensure that such information about such decisions is communicated in an appropriate and/or timely manner.
(3) There appeared to be no system of checking upon or auditing the systems referred to at paragraphs (1) and (2) above to ensure that the Responsible Clinician was receiving full, accurate and up to date information and that nursing staff were receiving appropriate and timely information about the Responsible Clinician’s decisions.
(4) There appeared to be no system to ensure that members of patients’ families were invited to be involved in the process by which decisions are made about their care, notwithstanding that they may often be able to impart useful information based upon the patient’s past behaviour, potentially including information about particular matters which might increase or decrease the risk of harm to or self-harm by such patients.
(5) The hospital’s procedure for responding to patients being absent without leave included reporting such patients to the police as missing persons, but did not appear to be adequate to ensure that members of staff so reporting, or thereafter giving further information, to the police had access to all of the information about the patient which was likely to be required by the police for the purpose of their enquiries.
6. Action Should be Taken In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action.
7. Your Response You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 January 2013. I, the coroner, may extend the period, and do hereby so extend it (in the light of the forthcoming Christmas vacation) to 18 January 2014.
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.
8. Copies and Publication I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
Continued/………
-3-
8 November 2013
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
9. Date: 8 November 2013
Yours sincerely,
Signed on behalf of N. A. Cameron Assistant Coroner By T. H. Ratcliffe, Assistant Coroner
Cc The Chief Coroner
Similar PFD reports
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.