Karen Sutton
4 Sept 2013 · Coroner Lydia Brown · Leicester City & South Leicestershire
The coroner's concerns
1. lack of communication to immunology team
“Not withstanding her 12 year history of regular Immunology follow-up, the team were not notified of her admission to hospital , on either occasion during August and September 2012, and thus given the opportunity to have input into her care and her discharge”
2. discharge without prophylactic antibiotics
“Mrs [name redacted] was discharged home without prophylactic antibiotic medication”
3. patient responsible for arranging follow-up appointment
“Mrs [name redacted] was left to arrange her next out patient appointment and it was fortuitous that was able to see her after the day of discharge, 4th October 2012”
4. lack of Trust-wide admission sharing policy
“was unaware of any Trust policy to share admissions between departments. He acknowledged this as a Learning point and although he has personally instigated a practice to encourage patients and /or their relatives to let his department know of any admissions, this is neither robust or in some circumstances practical and cannot be relied upon as a means of communication Trust-wide”
Responses
2013-0223-Response-by-University-Hospitals-of-Leicester.pdf ↗· University Hospitals of Leicester NHS Trust
Stated action
“The Medical Director has written to all Consultants in the Trust to remind them of their duty to contact specialist teams in the event of a patient with complex needs being admitted to hospital and placed under their care if a patient's care needs fall outside the Consultant's competence.”
Stated action · beginning of April 2014
“We have investigated the possibility of an IT solution. By the beginning of April 2014 we expect to have available to us a piece of software which will allow daily alerting to Consultants or their teams about any patient whom they have previously identified as individuals whose care needs are complex and who would therefore require specialist help from them or their team in the event of an admission to the Trust.”
Stated action · end of November 2013
“our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated.”
Stated action · end of November 2013
“Both of these actions will be concluded by the end of November 2013.”
Stated action
“the junior doctors involved in the care of Mrs [name redacted] will be particularly reminded about the importance of fully considering pre- admission medication.”
Stated action
“A plan was therefore made, prior to discharge, that Mrs [name redacted] should attend her pre-arranged appointment on 4th October 2012 with .”