Joseph Grantham

1. 1. delayed discharge paperwork

   “After his birth [the deceased] was transferred to the neonatal unit at St Mary's due to the complexities of his health. Following his discharge, it took 6 weeks for the trust to send the discharge paperwork to the GP and the District General Hospital (DGH) to whom they were transferring his paediatric care. As a result, there was no clear understanding amongst health professionals as to the paediatrician with responsibility for his care. Letters were therefore copied into a mixture of paediatricians.”

2. 2. delayed letter to paediatric anaesthetist

   “[the deceased] was under the care of the paediatric neurosurgical team at the Royal Manchester Children's Hospital (RMCH). Letters from the neurosurgical team following out-patient appointments took 4 weeks to be sent out. As a result one letter to a paediatric anaesthetist asking for an examination was not typed until after the operation was due to take place. When his mother took him for review, she had to escalate the need for him to be seen by the paediatric anaesthetist who then deemed him not fit”

3. 3. paper notes not available

   “At ENT appointments and neurosurgery appointments at the RMCH, [the deceased] was seen without the paper notes because they had not been made available to the clinicians seeing [the deceased]”

4. 4. lack of written instructions for community health professionals

   “[the deceased] had been diagnosed by the neurosurgeons at RMCH with neural tube defect (cervical meningocele, hydrocephalus, Amold Chiari type I! malformation. A recognised complication is hydrocephalus. Identification of the onset of hydrocephalus is through measurement of head circumference. The inquest heard that when [the deceased] was discharged from St Mary's the neurosurgical team did not send written instructions to community health professionals explaining what was required and why it was required.”

5. 5. incomplete red book

   “[the deceased]'s red book had been completed sporadically. The inquest heard from a number of witnesses who indicated that practice re completion of the red book amongst health professionals nationally was mixed and that there was no clear guidance for or expectation amongst health professionals that they would be widely used other than for post birth weight recording and immunisations. As a result there was no composite record of health concerns for a young child such as [the deceased]”

No published response was found on judiciary.uk.