Anita Loi
21 Feb 2020 · Coroner Jacqueline Devonish · London South
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. management of leg wound
“The Tissue Viability Nurse and District Nurses are a part of the same community team but no steps had been taken to attend to the management of [the deceased]'s leg wound despite repeated referrals by the GP and a call to the community team by the family.”
2. non-attendance at multidisciplinary meeting
“On 11 December 2019 the GP invited the District Nurses Team and Tissue Viability Nurses Team to attend a meeting at the surgery with the practice clinicians to review unexpected deaths and to discuss this case. Neither team attended the meeting and to date have not engaged with the GP in relation to this death despite a chasing letter.”
3. absence of appropriate policies
“whether there are appropriate policies, procedures protocols in place for the referral of patients to the service, and the response to such referrals”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“On 11 December 2019 the GP invited the District Nurses Team and Tissue Viability Nurses Team to attend a meeting at the surgery with the practice clinicians to review unexpected deaths and to discuss this case.”
Later report
“the initial assessment for Mr [name redacted] by the District Nurses did not record his next of kin details or what to do should the district nurse not be able to gain access.”
Responses
2020-0067-Response-from-Central-London-Community-Healthcare-NHS-Trust_Redacted.willbetrim.pdf ↗· Central London Community Healthcare NHS Trust
Stated action
“We have updated our Triaging Standard Operating Procedures to ensure a robust process for the management and response to referrals.”