Dorothy Cooper
21 Oct 2015 · Coroner Nicola Mundy · South Yorkshire (East)
The coroner's concerns
1. failure to provide key Information to the receiving team
“During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs [name redacted] to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team.”
2. incomplete clinical picture leading to patient risk
“My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.”
Responses
2015-0412-Response2.pdf ↗· Leeds Teaching Hospitals NHS Trust
Stated action · October 2014
“Hepatobiliary MDT Co-ordinator has re-circulated the pathway document that was updated in October 2014 and highlighted the need for completion of the referral form as fully and accurately as possible.”
2015-0412-Response.pdf ↗· Leeds Teaching Hospitals NHS Trust
Stated action · end of February 2016
“The main action to improve handover of cases like Mrs [name redacted] will be to embed the revised processes detailed in the Standard Operating Procedure being drafted subsequent to that review. We expect this will be embedded by the end of February 2016”
Cooper-2015-0412.pdf ↗· Leeds Teaching Hospitals NHS Trust