James Robertson
15 Feb 2016 · Coroner David Horsley · Portsmouth and South East Hampshire
The coroner's concerns
1. inaccurate time reporting of care checks
“carers were not required to accurately report the time of carrying out checks on him”
2. DNACPR status not clearly communicated
“whether a resident at Cams Ridge was covered by DNACPR was indicated by a coloured sticker on the door of the resident's room and in centrally-located notes”
3. inadequate emergency resuscitation packs
“there are no national standards for what should be included in emergency resuscitation packs kept at nursing homes”
4. missed DNACPR sticker causing delayed resuscitation
“The sticker on the door was not appreciated by a nurse who attended to him when he was found unresponsive and who then went to look in his notes, delaying resuscitation efforts”
Responses
No published response was found on judiciary.uk.