David White
11 Nov 2015 · Coroner Jacqueline Devonish · London Inner (North)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. confusion caused by Heparin
“The effect of Heparin, in causing confusion, was not in the records, and therefore not acted upon.”
2. lack of supervision for fall risk
“Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place. One to one care had been in contemplation.”
3. failure to review and act on nursing notes
“Whilst nursing notes were being kept about the risks, the records were not being reviewed and acted upon.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“(2) Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place. One to one care had been in contemplation.”
Later report
“3. The consequence of (2) was that no falls care plan was completed.”
Responses
2015-0437-Response.pdf ↗· Barts Health NHS Trust
Stated action
“The safety briefing during nursing handover is now to include a verbal handover of the care plans for patients assessed as at risk of falls to alert incoming staff members as to the risk and care plan.”
Stated action
“daily auditing of all nursing and falls risk documentation must be carried out.”
Stated action
“Multidisciplinary Team meetings on Ward 9F have now been changed to earlier in the day to discuss patients and make effective action plans for patient at risk of falls.”
Stated action
“A practice development team has been recruited to support ward staff in adhering to ward protocols and procedures including documentation, assessment of risks and communication.”
Stated action · 29 June 2015
“facilitated training from the 'Falls Lead' for the Trust to re-train nurses regarding the fall procedure and management and this took place on 29 June 2015.”
Stated action
“Site managers can now be contacted out of hours to ensure appropriate management of care.”