Charles Grainger
12 May 2018 · Coroner Rachel Syed · Derby and Derbyshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. information sharing failure
“Relevant information regarding Mr [name redacted] falls history could not be shared by his Social Worker with other relevant Multi Agencies such as Milford House or the Health Team at the time his Pre Admission Assessment was undertaken as the process/system did not allow it”
2. investigation omission
“a did not consider it important or necessary to request, review or retain copies of Mr [name redacted] falls risk assessment as part of her basic investigation enquiries”
Linked reports
Identical hazardConfidence 0.93 · high
This report
“Relevant information regarding Mr [name redacted] falls history could not be shared by his Social Worker with other relevant Multi Agencies such as Milford House or the Health Team at the time his Pre Admission Assessment was undertaken as the process/system did not allow it.”
Later report
“The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies; that impacted on their ability to review how other professionals would intervene in [the deceased]'s care.”
Responses
No published response was found on judiciary.uk.