Unclear discharge responsibility and lack of named consultant review prior to pa

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.

• 2019 → 2021Jacob Owczarek2 years 5 months after Kathleen McGeary · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight failures in assigning clear clinical responsibility for decisions affecting patient safety—one concerning adult discharge planning, the other concerning paediatric discharge review.

  Kathleen McGeary · 26 Feb 2019

  “No clinician took clear responsibility for discharge decision making. The recording of the identity of the discharging clinician was incorrect and communication between clinicians and nursing staff was unclear.”

  Check it in the source

  Jacob Owczarek · 28 Jul 2021

  “Lack of Named/Responsible Consultant review prior to a child's discharge”

  Check it in the source

  Stated action in the response to the earlier report

  “We have developed a new CDU(Clinical Decision Unit) standard operating procedure, which | attach, where it makes clear where responsibility lies for various aspects of the patient pathway. It also has CDU pathway document that aids the communication between the main hospital department and CDU on admission. This has now been implemented.”

  Earlier report in the app · Later report in the app