Lynsey Smalley
8 Sept 2023 · Coroner Kate Robertson · North West Wales
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of strategic governance
“there was no strategic plan or collaboration in governance processes”
2. paper based medical records
“medical records remain paper based not all individuals or organisations who need to understand a patient's circumstances/care/treatment are privy to all aspects of care/treatment”
3. loss of medical records
“Having medical records electronically will not only allow full access to all notes to those who require which will inform future care/treatment but will also ensure effective continuity of care, without the risk of missing or lost notes”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“It is clear that there was no strategic plan or collaboration in governance processes.”
Later report
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework.”
Responses
2023-0322-Response-from-Betsi-Cadwaladr-University-Health-Board.pdf ↗· Barts Health NHS Trust
Stated action · April 2024
“The Health Board is now fully reviewing the incident process to identify where it can be improved and strengthened. A workshop was held on the 23rd October 2023 to identify current issues and to begin the work of revising our process. The concerns you have identified in this notice, and in other notices, are being directly fed into this work.”