Lee Stammers
22 Aug 2025 · Coroner Louise Slater · South Yorkshire East
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. investigations not performed as requested
“Poor documentation, Communication, and systems- There were no clear communication, documentation, or systems in place, to identify if investigations had been performed as requested. For”
2. incomplete electrocardiography
“Electrocardiography was incomplete, not reported, or repeated”
3. blood tests not performed
“Blood tests were not performed as requested”
4. inaccurate information in medical records
“medical records indicated blood had been obtained and collected by the laboratory and the result was awaited.”
Linked reports
Closely relatedConfidence 0.86 · high
Earlier report
“There was evidence of poor record keeping on the ward. This included behaviour charts, enhanced patient supervision records and daily evaluation charts not being consistently recorded.”
This report
“Poor documentation, Communication, and systems- There were no clear communication, documentation, or systems in place, to identify if investigations had been performed as requested.”