Iris Fordham
5 Oct 2023 · Coroner Graeme Irvine · East London
This report repeats 1 earlier warning, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. poor quality of clinical records
“The poor quality of recording clinical records impeded the Trust's governance processes, in that the author of a serious incident investigation was unable to rely on clear evidence to understand why essential actions were not carried out in Ms [name redacted] care.”
2. lack of falls risk assessment
“The Trust failed to complete a falls risk assessment of Ms [name redacted].”
3. absence of falls care plan
“The consequence of (2) was that no falls care plan was completed.”
4. culture of indifference
“The fact that the failures at (2) & (3) were not detected and remediated by successive clinical staff members suggests that they did not read essential parts of the clinical record when providing care. The cumulative failings, on the part of multiple healthcare professionals suggests a culture of indifference inimical to the provision of safe and effective practice.”
5. lack of disciplinary or regulatory action
“The Trust has not considered any step to resolve individual failings in care through disciplinary or regulatory channels.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“(2) Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place. One to one care had been in contemplation.”
This report
“3. The consequence of (2) was that no falls care plan was completed.”
Identical hazardConfidence 0.90 · high
This report
“The poor quality of recording clinical records impeded the Trust's governance processes, in that the author of a serious incident investigation was unable to rely on clear evidence”
Later report
“The lack of contemporary documentation impeded an effective coronial investigation and review of that clinical decision.”
Identical hazardConfidence 0.90 · high
This report
“The poor quality of recording clinical records impeded the Trust's governance processes”
Later report
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent.”
Closely relatedConfidence 0.90 · high
This report
“The consequence of (2) was that no falls care plan was completed.”
Later report
“That the plan of care put in place specifically to reduce the risk of falls for multiple patients was not followed.”
Responses
2023-0373-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action
“all patients at risk of falls should have an up-to-date Enhanced Care Assessment which should be discussed at the multi-disciplinary meetings and of which the nurse in charge should be aware”