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Ethel Smith Leese

Ref: 2013-0184 Date: 7 Aug 2013 Coroner: Andrew Haigh Area: South Staffordshire Responses identified: 0 / 1 View PDF

Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's warfarin levels after her move to a care home and new GP practice.

Date 7 Aug 2013
56-day deadline 7 Oct 2013
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's warfarin levels after her move to a care home and new GP practice.
View full coroner's concerns
(1) There was one matter of concern which relates to the monitoring of Mrs Leese’s warfarin levels. The move to the care home required Mrs

Leese to be changed to a different GP practice. The checking by the hospital of Mrs Leese’s address (including the address for posting for the yellow booklet) appears to have been fairly chaotic. Her address on the paperwork seems to have remained unchanged, there appears

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Report details

Reference
2013-0184
Date of report
7 August 2013
Coroner
Andrew Haigh
Coroner area
South Staffordshire

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: 7 Oct 2013.

Sent to

Stafford Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.