Margaret Silver
3 Jan 2018 · Coroner Anna Crawford · Surrey
The coroner's concerns
1. inaccurate or contradictory medication information in discharge summaries
“The Discharge Summary contained contradictory information in relation to the future prescription of inpatient medication, which led to the medication being discontinued after 21 days when the intention was that it be taken for life”
2. failure to recognise discontinuation of anticoagulant therapy
“The fact that the Rivaroxaban had been discontinued was not identified by clinicians at St Peter's Hospital, despite Mrs [name redacted] attending the hospital on three occasions since her Rivaroxaban had been discontinued, and despite her informing them on 12 January 2016 that she thought it had been discontinued”
3. discharge planning failure to communicate occupational therapy recommendations
“Mrs [name redacted] was not provided with the equipment and support which had been recommend by the Occupational Therapist prior to her discharge on 3 February 2016. It was not possible to establish whether the information had in fact been passed on to the care home”