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Michael Longley

Ref: 2013-0370 Date: 19 Dec 2013 Coroner: Rachael Redman Area: Central & South East Kent Responses identified: 0 / 1 View PDF

Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral and written communication methods.

Date 19 Dec 2013
56-day deadline 12 Feb 2014
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral and written communication methods.
View full coroner's concerns
I heard evidence that Integrated Care 24 had difficulties in contacted the District Nursing Service on 25th December 2011 and I consider that improved methods of both oral and written communication between IC24 and the district nurses must be put in place.

Report sections

Investigation and inquest
On 17th and 18th October 2013 I commenced an investigation into the death of Michael Longley. My summary of evidence and conclusion were read at Folkestone Magistrates Court on 18th December 2013 when the inquest ended. The conclusion of the inquest was a Narrative Verdict.
Circumstances of the death
Mr M D Longley had an adverse reaction to Rivaroxaban which was administered after hip surgery which took place on 071211 at William Harvey Hospital, Ashford. Clexane was administered on 261211 by the district nurses. He was admitted to William Harvey Hospital on 311211 with an unrecordable platelet count and died the same day.
Action should be taken
I consider the training of District Nurses must now include that a patient should be examined if symptoms of bleeding have been reported.

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Related inquiry recommendations

Similar themes
Muckamore Abbey Inquiry Higher-funded resettlement team for complex needs Muckamore Abbey Inquiry Continuing community support provision Southport Inquiry GMMH local structured risk assessment responsibility Southport Inquiry GMMH and Alder Hey joint SMART audit Muckamore Abbey Inquiry Access to allied health professionals Muckamore Abbey Inquiry Whole-system commissioning with cross-agency risk assessment Muckamore Abbey Inquiry Consultation before patient transfers Muckamore Abbey Inquiry Named person approval for transfers Muckamore Abbey Inquiry Independent living skills focus Muckamore Abbey Inquiry Time frame and financial information for families

Report details

Reference
2013-0370
Date of report
19 December 2013
Coroner
Rachael Redman
Coroner area
Central & South East Kent

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 Feb 2014.

Sent to

Kent Community Health NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.