Doris Ridgwell
15 May 2018 · Coroner Anna Loxton · Surrey
The coroner's concerns
1. abnormal coagulation results not communicated to treating professionals
“The Trust's Standard Operating Procedure for Telephoning of Coagulation Results is not sufficiently clear regarding what action should be taken by staff in the Blood Sciences Department to ensure abnormal coagulation results are made known to the treating Healthcare professionals”
2. new SOP unclear for lab staff
“A new Standard Operating Procedure has been prepared, but having had sight of this, I do not believe this clearly outlines for Laboratory staff the steps to be taken in telephoning through abnormal Coagulation Results”
3. delayed availability of abnormal results on system
“Abnormal results are not authorised onto the Clinical Manager system to be viewed by Healthcare professionals by Laboratory staff until they have telephoned the results through to the ward, which can potentially cause a delay in these being available on the system”
4. discharge summaries omit blood test results
“The Discharge summaries provided to GPs following discharge from Hospital do not include blood tests results, meaning a potential safeguard to check these results is missed”