Harry Pryal
28 Sept 2015 · Coroner Alan Walsh · Manchester (West)
The coroner's concerns
1. lack of documented advice from WWL to Lakeside Unit clinicians
“During the Inquest evidence was heard that i. 5BP contact WWL for advice in relation to medical treatment for patients at the Lakeside Unit on a regular basis as a matter of rotocol. The Doctors in chiatry at the Lakeside Unit, are L_| dependent upon such advice for the treatment and care of | patients”
2. misinterpretation of Service Agreement clauses
“The Service Agreement entered into between 5BP and WWL for the period from the 1° April 2014 to the 31% March 2015 was the subject of different interpretations by each Trust. There was confusion in relation to the prioritisation of imaging and there was a fundamental conflict in relation the interpretation of clause 2.1”
3. delayed reporting of urgent clinical findings
“WWL do not have any triage procedures in relation to x-ray examinations so that any "urgent or unexpected significant Clinical finding" would not be reported to the referring clinician for some time after the examination”
4. inadequate clinical documentation
“The evidence at the Inquest revealed that the notes completed by clinicians at the Lakeside Unit, failed to identify the times of actions by them and in one note failed to identify the identity of the clinician making the note”
5. absence of physiotherapy and occupational therapy services
“there was no physiotherapy or occupational therapy at the Lakeside Unit to deal with the physical health needs of any patients on the Unit”