Recurance · prevention of future deaths reports
Pre-inquest brief
Incomplete patient transfer information
The earlier warning
Maureen Brown · 4 Feb 2020 · Emma Serrano, Derby and Derbyshire
“Evidence emerged during the inquest that the electronic transfer information is the only information that the receiving ward is given before a patient is transferred.”
judiciary.uk/prevention-of-future-death-reports/maureen-brown
What was promised
Stated action 1 · response to Maureen Brown (4 Feb 2020) · stated timescale: none stated
“the Trust has responded to address the specific learning with regard their own internal patient transfer processes.”
judiciary.uk/…/2020-0021-Response-from-NHS-England-and-NHS-Impr…
What recurred
- 14 Oct 2020 · Edward Cowey · Emma Serrano · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Maureen Brown · 4 Feb 2020
“Evidence emerged during the inquest that the electronic transfer information is the only information that the receiving ward is given before a patient is transferred.”
Later · Edward Cowey · 14 Oct 2020
“Evidence emerged during the inquest 1. That patient electronic and paper based transfer information is not kept on one database.”
What happened next
No web check of the stated actions has been published for this chain.