Derek Holmes

22 Jun 2022 · Coroner Chris Morris · Manchester South

The coroner's concerns

1. investigation errors
“Notwithstanding the fact that the document had passed through the Trust's quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr [name redacted] fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths”
2. inadequate learning from investigation
“The formal learning derived from the Trust's investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as: - the adequacy of existing processes designed”
3. grading error
“Connected with the above, the Trust does not appear to have revisited the grading of”