Janet Spencer
4 Oct 2023 · Coroner Michael Wall · Nottingham City and Nottinghamshire
The coroner's concerns
1. inadequate risk assessment and care plan during discharge and transfer
“systems in place in respect of discharge to assess patients do not appear to ensure patients are discharged or transferred between care facilities with an adequate and up to date risk assessment and care plan in place”
2. inadequate information sharing during transfers
“systems in place in respect of discharge to assess patients do not appear to ensure a smooth transition between care facilities, especially when transfers are arranged at pace. In particular, they do not appear to ensure that all involved have the information they require to contribute effectively to the transfer process”
3. medication administration errors during transfer
“An error occurred between the care facilities which resulted in [the deceased] not receiving two of her prescribed medications following her transfer to Gladstone House”