Evelyn Kennedy
7 May 2015 · Coroner Veronica Hamilton-Deeley · Brighton & Hove
A similar concern from this report was raised again 3 times later. See the linked reports.
The coroner's concerns
1. Acute Medical Unit (AMU)
“Once again my concerns involve the Acute Medical Unit (AMU).”
2. transfer in chair
“Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.”
3. incomplete handover
“Handover was incomplete and unhelpful.”
4. porridge leakage and inadequate mouth care
“She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.”
5. patient feeling cold
“She felt cold and said she was cold.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. | (4) She arrived unkempt”
Later report
“handover relies more and more on the notes and the notes are relying more and more on tick boxes which are simply not adequate to deal with the individualities of each patient.”
Closely relatedConfidence 0.80 · moderate
This report
“(3) Handover was incomplete and unhelpful. |”
Later report
“Failure in training and post training monitoring for Trust staff and lack of control over training for agency staff using hazardous substances. Failures in supervisory staff in the housekeeping department (particularly those on the fourth floor of the Thomas Kemp Tower) to adhere to their own practices and requirements eg.”
Closely relatedConfidence 0.92 · high
This report
“Handover was incomplete and unhelpful.”
Later report
“His discharge documentation which acts as a handover for his Doctors was barely completed and this lack of completion is unacceptable.”
Responses
2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust.pdf ↗· Brighton and Sussex University Hospitals NHS Trust
Stated action · last autumn
“The Trust introduced a new clinical management structure last autumn, a very few weeks before Mrs [name redacted] last admission. The clinical team now managing the acute medical unit have worked tirelessly to introduce a range of changes in order to improve the functioning and quality of the Acute Medical Unit. These incorporate a range of actions relating to the workforce, education, environment, equipment, patient flow, teamwork and communications.”