James Withers
7 Jan 2014 · Coroner John Pollard · Manchester (South)
A similar concern from this report was raised again 3 times later. See the linked reports.
The coroner's concerns
1. delayed cardiology review
“There was a delay of five days between the Cardiologist being requested to see the patient and actually attending the patient”
2. missing medical and nursing notes
“Various of the medical/nursing notes appear to have gone missing”
3. DNAR decision made without family consultation
“The patient's DNAR status was fixed without any reference to/discussion with his family”
4. incorrect DNAR status assumption
“One of the doctors admitted that he had assumed an incorrect DNAR status based on the fact that he had two separate pieces of paper in his pocket and had looked at the wrong one”
5. poor interdisciplinary and family communication
“There was generally poor communication between nursing and medical staff (inter se) and between medical/nursing staff and the family of the patient”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“There was generally poor communication between nursing and medical staff (inter se) and between medical/nursing staff and the family of the patient.”
Later report
“There was extremely poor communication between hospital staff and the patient (and her family), and between and amongst themselves.”
Closely relatedConfidence 0.80 · moderate
This report
“There was generally poor communication between nursing and medical staff (inter se) and between medical/nursing staff and the family of the patient.”
Later report
“There was no apparent handover from the hospital to this ward, as to the individual needs of the patient, and the staff were therefore placed in an impossible position.”
Identical hazardConfidence 0.90 · high
This report
“There was generally poor communication between nursing and medical staff (inter se) and between medical/nursing staff and the family of the patient.”
Later report
“There was clear evidence that the medical staff were not reading (or even looking at) the nursing notes, and the nurses were similarly not looking at the medical entries.”
Responses
No published response was found on judiciary.uk.