Irshad Ali
29 Aug 2014 · Coroner ME Hassell · London Inner (North)
The coroner's concerns
1. lack of regular monitoring of patient
“The nursing staff should have checked on Mr [name redacted] every two hours through the night, but there was no record of intentional rounding on 24/25 March”
2. missing neurological observations after fall
“Though the senior sister looking after Mr [name redacted] on the morning of 25 March assured me that neurological observations were carried out hourly after his fall, there was no record of this”
3. failure to conduct required neurological assessments before discharge
“The consultant in charge of Mr [name redacted] care stipulated that his junior medical colleagues should perform neurological observations before Mr [name redacted] could be discharged, yet this did not take place”
4. physiotherapy assessment not performed before discharge
“The consultant in charge of Mr [name redacted] care also stipulated that Mr [name redacted] should undergo physiotherapy assessment before he could be discharged, yet this did not take place”
5. absence of nurse support during medical rounds
“Both the doctor and the nurse thought that it would be helpful to have a nurse accompany the doctors on their ward rounds”
Responses
2014-0387-Response-by-Barts-Health-NHS-Trust.pdf ↗· Barts Health
Stated action
“During the investigation, senior qualified nursing staff contacted the nurse allocated to care for Mr Alli on the night of 24/15 March 2014, who confirmed that the intentional rounding did také place.”