Elaine Jobe
14 Jul 2014 · Coroner Dr Elizabeth Earland · Exeter & Great Devon
A similar concern from this report was raised again 3 times later. See the linked reports.
The coroner's concerns
1. lack of record keeping
“lack of record keeping on the Ri O of (i) Risk Assessments and details of those persons making the assessments. (ii) Lack of information regarding the Levels of Observations and the persons actually making the observations. (2)Training Records of training of staff in the making of Risk Assessments and in understanding the meaning of the different Levels of Obs. and implementation of same. (3)Communication of patient status to incoming staff Communication of patient status with other members of staff”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“lack of record keeping on the Ri O of (i) Risk Assessments and details of those persons making the assessments.”
Later report
“Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in plan”
Closely relatedConfidence 0.90 · high
This report
“lack of record keeping on the Ri O of (i) Risk Assessments and details of those persons making the assessments.”
Later report
“Two types of risk assessments were completed, with no system to ensure that important information is present on both;”
Closely relatedConfidence 0.80 · moderate
This report
“Lack of information regarding the Levels of Observations and the persons actually making the observations.”
Later report
“[the deceased]'s observations charts were not filled out adequately or at all on the date of his death”
Responses
2014-0350-Response-by-Devon-Partnership-NHS-Trust.pdf ↗· Devon Partnership NHS Trust
Stated action · January 2015
“The Trust has Best Practice and Consistency of Recording on Rio for inpatient services, which includes risk assessments. Within 7 hours of admission, a risk assessment is completed by the admitting nurse and doctor. The time and names of the staff completing the assessment are automatically generated and inputted by the electronic patient record system on Rio.”