Francis Beech
12 Dec 2017 · Coroner Louise Hunt · Birmingham and Solihull
The coroner's concerns
1. high risk fractures treated conservatively
“Lack of clear guidelines regarding the management of high risk fractures treated conservatively”
2. lack of continuity of care
“Lack of continuity of care”
3. lack of weekly x-rays after discharge
“Failing to arrange weekly x-rays after discharge to check for fracture alignment and to monitor the fracture”
4. lack of outpatient appointment within 3 weeks of discharge
“Failing to arrange an outpatient appointment within 3 weeks of discharge”
5. lack of information to nursing home about high risk plaster cast
“Failing to provide any information to the nursing home about the need to monitor the plaster cast and that it was high risk”
6. lack of documentation of pus on cast
“Failing to document pus on the cast when he attended for a hip x-ray on 01/07/17”
Responses
2017-0367-Responses.pdf ↗· Heart of England NHS Trust
Stated action · 31 March 2018
“The Trust accepts that, at the time of Mr [name redacted] death, there were no Trust guidelines in existence regarding the management of potentially unstable fractures in frail patients that are for conservative (non-operative) treatment. Following the findings from this report, guidelines will be formulated for clinicians to follow for these patients. These will include recommended timescales for follow-up and x-ray reviews to be used in conjunction with clinical judgement. The new guidelines will be”