Jaipreet Panesar
25 Nov 2024 · Coroner Heidi Connor · Berkshire
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of care co-ordinator or key worker
“no care co- ordinator or key worker was provided to [name redacted] after her discharge from hospital on 7th of September 2022”
2. inability to access clinical notes across systems
“It is still not possible for teams using RiO and the BTT systems to access each other's clinical notes”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“supervision within teams and cross-supervision between teams, particularly of the critical role and caseload of care coordinator, may still lack robustness.”
This report
“no care co- ordinator or key worker was provided to [name redacted] after her discharge from hospital on 7th of September 2022.”
Responses
2024-0645-Response-from-Oxford-Health-NHS-Foundation-Trust-.pdf ↗· Oxford Health NHS Foundation Trust
Stated action · January 2025
“The Trust's initial plan was to review this by June 2024, and the aim now is for January 2025, almost two years from [name redacted]'s death.”
Stated action · November 2024
“secondary care services have access to a system called Thames Valley & Surrey (TVS) Shared Care Records/Graphnet, to which system BTT has uploaded patient information dating back to 1st May 2022. This upload concluded in November 2024.”
Stated action · 12th December 2024
“guidance on the use of Thames Valley & Surrey Shared Care Records and this guidance was most recently updated on 12th December 2024.”