Carmella Kerr

RECOMMENDATIONS I now turn to deal with the recommendations that I make as a result of this inquiry. I am bound to say the list would have been considerably longer were it not for what came out in evidence as to steps which have been taken since this occurrence and which list would have encompassed paragraphs one to five of the preceding section. The recommendations I make are as follows: - 1. It should be emphasised to all grades that there is a necessity to make proper full intelligible and legible notes of observations that they make, any action which they carry out, and any action which they intend others to carry out: and in that last case, who is to carry it out should be specified. I regard this as absolutely essential in a situation where there is constant shift change and hand-over. Although the question of hand-over has been addressed to an extent, proper and adequate notes form the basis upon which anyone examining the history of a patient has to base an assessment, which history might cover something not dealt with at hand-over. 2. In regard to a protocol for requesting a surgical review - indeed any interdepartmental review - I recommend that such always be made by and to at least a middle-grade member of staff in the referring and referee departments. 3. I recommend that the protocol for "chasing up" an inter-departmental review should have a time limit put upon it and not be left to individuals to estimate what is a "reasonable time". I appreciate that there will be different levels of urgency but there should be a finite time during which if not carried out the referring SHO should be obliged to consider whether or not a further prompt is required and should record that he or she has so considered in the notes and either decided to wait longer or to repeat it - and should assign in the notes a reason for that decision. Although I understand it has already been put in place, an additional paragraph should be inserted to cover as part of this protocol that a record be made in these notes as to who is to be responsible for undertaking the next steps. 4. I recommend that the system for ordering x-rays and other radiological procedures should be re-examined with a view to simplification and that all staff who are authorised to make such requests be clearly instructed as to the way in which the radiology department receives and treats them and as to the implications of the content of such requests and the time limits in which the radiology department will carry them out.