Jane Robinson
10 Feb 2015 · Coroner Catherine Mason · Leicester (City & South)
The coroner's concerns
1. lack of recorded basic observations
“Basic observations repeatedly not being recorded”
2. absence of senior shift review for observation shortfalls
“No evidence of on-going senior review on each shift whereby shortfalls in observations would be detected at an early stage”
3. absence of documented rationale for observation frequency
“Lack of written decision making rational in relation to the frequency of observation”
4. lack of reporting system and support for non-compliant professionals
“No evidence of any reporting system of healthcare professionals that do not practice in accordance with accepted standards and no evidence of support given to those who do report”