Joyce Hartford
15 Jul 2015 · Coroner Lisa Hashmi · Manchester (North)
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. incomplete and inaccurate nursing records and documentation
“During the course of the inquest hearing it became apparent that the nursing tools (in particular, the 'Purpose T'), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate. Whilst I was told that the Trust, to its credit, had been conducting audits since the Summer of 2014 in order to improve nurse record keeping, Mrs [name redacted] died in January 2015 and the evidence at inquest did not disclose any material improvement in overall standards. As”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“During the course of the inquest hearing it became apparent that the nursing tools (in particular, the 'Purpose T'), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate.”
Later report
“Staff did not follow the Trust's protocols/guidance and did not document their rationale where - they exercised clinical discretion”
Closely relatedConfidence 0.85 · high
This report
“During the course of the inquest hearing it became apparent that the nursing tools (in particular, the 'Purpose T'), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate.”
Later report
“Gaps within the documentation/record keeping/missing entries by both doctors and nurses (including fluid balance charts for a patient in heart failure and subject to fluid restriction, risk assessments, care planning, rounding tool and medical attendance upon the deceased).”
Responses
2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust.pdf ↗· Pennine Acute Hospitals NHS Trust
Stated action · July 2015
“We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited using the nursing metrics which includes the quality of record keeping.”
Stated action · January 2015
“¢ Since January 2015 Ward T7 has recruited into a number of vacant registered nurse posts; as part of the induction for these new staff we have developed an induction booklet which includes the requirement for a senior member of the nursing team to observe the staff member undertaking various tasks to confirm that these are being performed competently - this includes completion of documentation such as District Nurse referrals, SKIN bundles (for tissue viability) and Rounding Tools”
Stated action · Ongoing
“There are also weekly audits of documentation undertaken by the Clinical Matron/Unit Manager and the Band 6 Sisters and feedback is given to the relevant member of staff at the time of the audit. These include accurate and timely completion of risk assessments, use of appropriate care plans and timely reassessments.”
Stated action · Ongoing
“SKIN bundle training has also been provided by the Equipment Co-ordinator who is a member of the Tissue Viability team.”
Stated action · Ongoing
“For early detection and management of pressure ulcers the use of scenario training on the completion of the PurposeT tool is now in place.”
Stated action · August 2015
“Since February 2015, the Unit has achieved 90% and above in the Nursing Care Indicators Audit except for May when the results reduced to 84% and this reduction was responded to immediately recognising that this was related to a trial of incorporating nursing documentation within the medical records. This was addressed and results improved to 92% in June, 95% in July and 93% in August.”