Recurance · prevention of future deaths reports
Pre-inquest brief
Unclear discharge responsibility and lack of named consultant review prior to pa
The earlier warning
Kathleen McGeary · 26 Feb 2019 · Stephanie Haskey, Nottinghamshire
“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.”
judiciary.uk/prevention-of-future-death-reports/kathleen-mcgeary
What was promised
Stated action 1 · response to Kathleen McGeary (26 Feb 2019) · stated timescale: now
“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.”
judiciary.uk/…/2019-0081-Response-by-Doncaster-and-Bassetlaw-Ho…
What recurred
- 28 Jul 2021 · Jacob Owczarek · Dr Elizabeth Didcock · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · Jacob Owczarek · 28 Jul 2021
“Lack of Named/Responsible Consultant review prior to a child's discharge”
What happened next
No web check of the stated actions has been published for this chain.