Medication monitoring and discharge risk assessment failures

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2018 → 2020Sean Owen2 years 3 months after Astonn Mitchell-Male · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight failures in documenting and communicating medication‑related risks, specifically around patient non‑compliance. The earlier report notes a missing policy for medication monitoring and triangulation, while the later report shows discharge letters omitting risk of non‑compliance.

  Astonn Mitchell-Male · 26 Jul 2018

  “There is no policy in existence within the Trust to address the process of patient medication monitoring/compliance and the triangulation of corroborative information, particularly within the community setting.”

  Check it in the source

  Sean Owen · 23 Oct 2020

  “The Discharge Letter that was sent to Mr [name redacted] GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2020 → 2024David Thompson3 years 10 months after Sean Owen · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight failures in the discharge process where critical risk information was omitted or not documented. The earlier case concerned missing details in discharge summary letters; the later case concerned absent discharge clinical entries and risk assessments.

  Sean Owen · 23 Oct 2020

  “The Discharge Letter that was sent to Mr [name redacted] GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician.”

  Check it in the source

  David Thompson · 12 Aug 2024

  “A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.”

  Check it in the source

  Stated action in the response to the earlier report

  “The Clinical Director for the Borough has established process that ensures: - All new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries. - During their first month working on the wards all new trainees have their written admission/discharge summaries checked and discussed at the ward round held prior to discharge of the patient. A senior doctor checks the documentation.”

  Earlier report in the app · Later report in the app

• 2016 → 2024David Thompson8 years 5 months after Susan George · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight failures in the discharge process where essential documentation or review was omitted. They differ in focus: the earlier case stresses lack of a clinical review when the patient’s condition changed, while the later case notes missing discharge clinical entry, risk assessment, and crisis information.

  Susan George · 29 Feb 2016

  “No review of the decision to discharge was sought or conducted when it became apparent that there had been a material change in [the deceased]'s presentation on the 10th November.”

  Check it in the source

  David Thompson · 12 Aug 2024

  “A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.”

  Check it in the source

  Stated action in the response to the earlier report

  “The discharge assessment document is prepared prior to planned discharges and is then completed on the day of discharge by the discharge nurse. The final page of this document is the 'Discharge Plan' which contains the emergency contact numbers and a crisis contingency plan. A copy of this is handed to the patient upon discharge.”

  Earlier report in the app · Later report in the app