Inadequate transfer assessment and documentation

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.

• 2023 → 2025Patricia Catterall1 year 7 months after Richard Griffiths · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight deficiencies in the transfer of care process that could compromise patient safety. The earlier report focuses on missing detail in the Transfer of Care document, while the later report concerns inadequate pre‑transfer assessment by the nursing home.

  Richard Griffiths · 14 Sept 2023

  “The Health Board's Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur.”

  Check it in the source

  Patricia Catterall · 11 Apr 2025

  “That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed”

  Check it in the source

  Stated action in the response to the earlier report

  “incidents. The Transfer and Discharge of Care Protocol has been revised to include explicit guidance relating to transfers of care between community teams. This includes the steps to be taken by the care coordinator, supporting administrative staff and the single point of access service (SPOA). Progression of this protocol through the Health Board ratification process is being led by the MH&LD Deputy Director of Nursing and progress is overseen by the MH&LD Policy and Procedure Group. The revised protocol”

  Earlier report in the app · Later report in the app