Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Iris Fordham · 5 Oct 2023 · Graeme Irvine, East London
“The poor quality of recording clinical records impeded the Trust's governance processes”
judiciary.uk/…/iris-fordham-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Iris Fordham (5 Oct 2023) · stated timescale: none stated
“all patients at risk of falls should have an up-to-date Enhanced Care Assessment which should be discussed at the multi-disciplinary meetings and of which the nurse in charge should be aware”
judiciary.uk/…/2023-0373-Response-from-Department-of-Health-and…
Stated action 2 · response to Thomas Doyle (20 Oct 2023) · stated timescale: none stated
“seriously and has taken positive action to address those issues. To improve standards, an internal alert and a screen saver has been shared with staff which details good record keeping standards that should be adhered to by all staff as well as a video which has been developed with the Medical Director explaining the importance of good record keeping.”
judiciary.uk/…/2023-0397-Response-from-Department-of-Health-and…
Stated action 3 · response to Thomas Doyle (20 Oct 2023) · stated timescale: none stated
“1 The Trust sepsis education programme is essential for all clinical staff and has recently been updated. This is supported by additional face to face training for doctors and nurses. The Trust has adopted the UK Sepsis Trust`s adult screening tool and the use of this is audited by the Lead Nurse for Sepsis. Audits include patients who have scored over 5 on the National Early Warning Score to ensure that Sepsis was considered. In addition, all positive blood culture cases are audited to ensure”
judiciary.uk/…/2023-0397-Response-from-Department-of-Health-and…
4 further stated actions are listed on the full chain page.
What recurred
- 20 Oct 2023 · Thomas Doyle · Graeme Irvine
- 4 Jul 2024 · David Morris · Graeme Irvine · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Thomas Doyle · 20 Oct 2023
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation”
Later · David Morris · 4 Jul 2024
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent. The absence of clear records impeded the effective investigation”
What happened next
No web check of the stated actions has been published for this chain.