Ann Pickering

4 Jul 2022 · Coroner David Urpeth · South Yorkshire Western

The coroner's concerns

1. lack of clear policies and procedure for transferring patients under a section
“There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them.”
2. delay in inserting NG tube after recognition of need
“There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required.”
3. delay in accepting patient transfer
“Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer”
4. delayed insertion of NG tube
“Despite recognising an NG tube was required, one was not inserted until the 30.6.21”