Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Joyce Hartford · 15 Jul 2015 · Lisa Hashmi, Manchester (North)
“During the course of the inquest hearing it became apparent that the nursing tools (in particular, the 'Purpose T'), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate.”
judiciary.uk/prevention-of-future-death-reports/joyce-hartford
What was promised
Stated action 1 · response to Joyce Hartford (15 Jul 2015) · stated timescale: July 2015
“We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited using the nursing metrics which includes the quality of record keeping.”
judiciary.uk/…/2015-0279-Response-by-Pennine-Acute-Hositals-NHS…
Stated action 2 · response to Joyce Hartford (15 Jul 2015) · stated timescale: January 2015
“¢ Since January 2015 Ward T7 has recruited into a number of vacant registered nurse posts; as part of the induction for these new staff we have developed an induction booklet which includes the requirement for a senior member of the nursing team to observe the staff member undertaking various tasks to confirm that these are being performed competently - this includes completion of documentation such as District Nurse referrals, SKIN bundles (for tissue viability) and Rounding Tools”
judiciary.uk/…/2015-0279-Response-by-Pennine-Acute-Hositals-NHS…
Stated action 3 · response to Joyce Hartford (15 Jul 2015) · stated timescale: Ongoing
“There are also weekly audits of documentation undertaken by the Clinical Matron/Unit Manager and the Band 6 Sisters and feedback is given to the relevant member of staff at the time of the audit. These include accurate and timely completion of risk assessments, use of appropriate care plans and timely reassessments.”
judiciary.uk/…/2015-0279-Response-by-Pennine-Acute-Hositals-NHS…
10 further stated actions are listed on the full chain page.
What recurred
- 30 Jun 2016 · Dominic Smith · Lisa Hashmi · Closely related · confidence 0.90 (high)
- 28 Nov 2017 · John Lea · Lisa Hashmi · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Joyce Hartford · 15 Jul 2015
“During the course of the inquest hearing it became apparent that the nursing tools (in particular, the 'Purpose T'), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate.”
Later · Dominic Smith · 30 Jun 2016
“Staff did not follow the Trust's protocols/guidance and did not document their rationale where - they exercised clinical discretion”
What happened next
No web check of the stated actions has been published for this chain.