Graham Jones
18 Apr 2019 · Coroner Katy Skerrett · Gloucestershire
The coroner's concerns
1. falls on surgical ward
“Whether sufficient consideration is given to falls prevention measures on the surgical ward”
2. post falls protocol understanding
“Whether there is sufficient understanding of the post falls protocol that must be followed on the surgical ward”
3. medication review after fall
“Whether there is sufficient understanding that a medical review of a patient post fall must include review of their current medications”
4. handover of safety information
“When a patient is transferred between wards, whether there is sufficient handover of safety information pertaining to a patient”
Responses
2019-0131-Response-by-Gloucestershire-Hospitals-NHS-Trust.pdf ↗· Gloucestershire Hospitals NHS Trust
Stated action
“The Trust proposes to undertake some work to address the fact that low dose prophylactic anticoagulants in the form that Mr [name redacted] received must be included in this medical assessment, and instructions given to nursing staff as to whether this medication should be continued or stopped. This likely to include redrafting part of the post falls sticker to this effect, and providing accompanying training to doctors about this change, and the reason for it.”