Gareth Etchells-Height
20 Nov 2023 · Coroner Alexandra Pountney · South Yorkshire (Western)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inadequate discharge planning
“Discharge and safety netting”
2. inconsistent medical note review
“Review of the medical notes”
3. outdated risk assessment
“Failure to update risk assessment”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“It was accepted at the inquest that more could have been taken into account in risk assessing Mr [name redacted].”
This report
“There was a failure to update [the deceased]'s risk assessment, which at the date of his death was last updated on 7 April 2022.”
Responses
2023-0517-Response-from-Sheffield-Health-and-Social-Care.pdf ↗· Sheffield Health and Social Care NHS Foundation Trust
Stated action · end of February 2024
“We will complete and audit existing practice in relation to the completion of our discharge summaries and the process and documentation in support of safety netting. We will also review the format and function of our existing discharge templates. These tasks will be completed by the end of February 2024.”
Stated action · end of June 2024
“The new discharge template will be completed by the end of June 2024 and the launch of this will be supported by local best practice training by the Directorate Leadership Team.”
Stated action · 30 April 2024
“The Directorate Leadership Team will develop a Standard Operating Procedure covering 'how to prepare for a clinical review` which will include what documentation should be read as part of the preparation for this by 30 April 2024.”
Stated action
“The individual practitioners involved in the review of care are aware of the importance of reviewing and updating risk assessments for individual clients. As we move to our new electronic patient record, this will give us opportunity to set review requirements as an automated reminder in addition to individual clinical judgement.”
Stated action
“We will request regular reporting on clinical record keeping audits and monitor progress via our Directorate Leadership Teams into the Clinical Quality and Safety Group.”
Stated action
“The implementation of the system has been delayed for some services in the Trust, however, the functionality of RIO will bring about significant automated improvements in record keeping.”
2023-0517-Response-from-Sheffield-Health-and-Social-Care-Update.pdf ↗· Sheffield Health and Social Care NHS Foundation Trust
Stated action · 30 June 2024
“The Clinical Director for Acute and Community Services has provided instruction via email to all inpatient Responsible Clinicians that diagnoses must be captured in Insight (our electronic patient record system) to enable them to be pulled through onto the discharge summary.”
Stated action
“We developed a clinical record keeping standards policy earlier this year to provide clarity on the expected requirements to ensure high quality, person centred clinical documentation across the Trust.”
Stated action
“Live dashboards have been developed for use by our community teams. These dashboards show staff at any given point in time when key documents were updated and what requires their attention to review, revise or update.”
Stated action
“All staff have been reminded about the importance of good quality record keeping through an alert cascade that was produced, disseminated and published on the staff intranet.”