Laura Booth
5 May 2021 · Coroner Abigail Combes · South Yorkshire (West District)
The coroner's concerns
1. lack of knowledge of Mental Capacity Act
“I am satisfied and remain gravely concerned about the lack of knowledge, respect and application of the Mental Capacity Act principles amongst staff treating patients who may not have capacity to make decisions for themselves”
2. lack of patient and family involvement in decisions
“[the deceased] was non verbal but she could communicate. There was no evidence of anyone seeking [the deceased]'s parents' views in a way which would be compliant with the Mental Capacity Act and even more worryingly, no evidence of clinical teams seeking [the deceased]'s views at all”
3. inadequate best interests documentation
“There was evidence in the clinical notes of one best interests form completed for [the deceased]'s admission for her eye surgery. The completion of this form, whilst a positive that it had been completed and is evidence that best interests had been considered, remains woefully inadequate in details and upon further exploration it was apparent that no attempt had been made to engage [the deceased] in the decision making”
4. inappropriate death verification
“I remain concerned that all staff treating [the deceased] have expressed the view that they did not expect [the deceased] to die in this admission and were very upset when she did. I am therefore at a loss as to why the verification of death form records her as being an expected death”
5. lack of awareness of hospital passport
“I also remain concerned at a lack of understanding about the importance and relevance of [the deceased]'s hospital passport”
Responses
2021-0137-Response-from-Northern-General-Hospital_Published.pdf ↗· Sheffield Teaching Hospitals NHS Foundation Trust
Stated action
“agreed to ensure the appropriate dissemination of information relating to MCA across relevant staff groups, in order to raise awareness.”