Astonn Mitchell-Male
26 Jul 2018 · Coroner Lisa Hashmi · Manchester (North)
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of medication monitoring policy
“There is no policy in existence within the Trust to address the process of patient medication monitoring/compliance and the triangulation of corroborative information, particularly within the community setting.”
2. poor record keeping
“There was evidence to show that record keeping was poor and at some points non-existent. Records are a vital form of communication about the patient's condition and care provision. As such, poor compliance goes to the issue of patient safety.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“That the GP's recollection of events was not supported by contemporaneous record keeping, thus calling into question accuracy.”
This report
“There was evidence to show that record keeping was poor and at some points non-existent.”
Closely relatedConfidence 0.90 · high
Earlier report
“Poor record keeping, predominantly on the part of the nursing staff.”
This report
“There was evidence to show that record keeping was poor and at some points non-existent.”
Closely relatedConfidence 0.80 · moderate
This report
“There is no policy in existence within the Trust to address the process of patient medication monitoring/compliance and the triangulation of corroborative information, particularly within the community setting.”
Later report
“The Discharge Letter that was sent to Mr [name redacted] GP on 6 February 2019 was prepared by a doctor who had little involvement in his care and was not counter-checked by a senior clinician.”
Responses
No published response was found on judiciary.uk.