Lauren Bridges (1)
19 Sept 2023 · Coroner Andrew Bridgman · Manchester South
This report repeats 3 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed discharge of Out-of-Area patient
“This is the second inquest I have heard where the delayed discharge/repatriation of an Out-of-Area patient from an independent provider's hospital has been a contributory factor in that patient's death”
2. inadequate communication
“The jury identified inadequate and insufficient communication between Dorset Healthcare NHS Trust, The Priory and relevant parties”
3. absence of national standard process
“There is no national standard process for referrals into the independent sector nor for discharge/repatriation to the 'home team'”
4. excessive number of commissioning bodies
“The Priory deals with 42 NHS separate commissioning bodies”
5. incompatible record keeping systems
“multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process.”
This report
“There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.”
Closely relatedConfidence 0.90 · high
Earlier report
“. The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.”
This report
“There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.”
Identical hazardConfidence 0.90 · high
Earlier report
“incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult”
This report
“There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.”
Identical hazardConfidence 0.95 · high
This report
“This is the second inquest I have heard where the delayed discharge/repatriation of an Out-of-Area patient from an independent provider's hospital has been a contributory factor in that patient's death.”
Later report
“delayed transfer of an out-of-area patient from an independent provider's hospital has been a contributory factor in that patient's death”
Responses
2023-0438-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2023-0438-Response-from-Dorset-Healthcare-University-NHS-Foundation-Trust.pdf ↗· Department of Health and Social Care
Stated action
“The Trust has undertaken a comprehensive review to ensure that all patients who are receiving acute care funded by the Trust in Out of Area beds are accurately identified as such on our clinical system.”
Stated action
“We have enhanced the daily Hospital Overview situation report which is accurate at the point it is sent, with the purpose of providing a summary at the start of the working day across the organisation to key colleagues including senior clinicians and managers.”
Stated action
“In addition, the Trust has also added a specific section to the daily Hospital Overview template showing patients who are in out of area beds who require repatriation to a local bed.”
Stated action
“We have updated the electronic admission form template that is embedded in the patient record system so that when a patient requires admission, we capture more robust information, which is then also reportable in a bed state automated report.”
Stated action
“The Trust has implemented a new Standard Operating Procedure (SOP) for Enabling Purposeful Admissions. This clearly sets out the required process, roles and responsibilities of key staff and the required recording in respect of inpatient flow decisions.”
Stated action
“We have reviewed our daily clinical meeting that takes place in respect of bed flow and set out requirements in the meeting's terms of reference, including standard items for discussion and recording standards.”
2023-0438-Response-from-NHS-England.pdf ↗· NHS England
Stated action · 2023/24
“All Integrated Care Boards (ICBs) were asked to work towards eliminating the practice in NHS England's 2023/24 Priorities and Operational Planning Guidance.”