Lack of risk assessment documentation and updates

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.

• 2015 → 2017John Lea2 years 5 months after Toni Piel · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight failures to perform or update required risk assessments for patients. The earlier case concerns discharge risk factor assessment, while the later case concerns ongoing assessments such as falls and cot side checks.

  Toni Piel · 9 Jul 2015

  “No assessment of the risk factors in discharging the deceased was documented in the deceased's records.”

  Check it in the source

  John Lea · 28 Nov 2017

  “In this case, critical risk assessments had not been updated and/or completed (falls, cot sides etc.) There were missed opportunities to re-assess.”

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  Earlier report in the app · Later report in the app

• 2015 → 2019Marjorie Gartside3 years 8 months after Toni Piel · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight deficiencies in the hospital's discharge process that could lead to unsafe patient release.

  Toni Piel · 9 Jul 2015

  “No assessment of the risk factors in discharging the deceased was documented in the deceased's records.”

  Check it in the source

  Marjorie Gartside · 12 Mar 2019

  “That the information provided by the Royal Oldham Hospital to the Home on 10 October 2018 was inaccurate in suggesting that Mrs [name redacted] was able to mobilise.”

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  Earlier report in the app · Later report in the app