Marie Zarins
14 Aug 2023 · Coroner Isobel Thistlethwaite · Leicester City and South Leicestershire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. incorrect medication information in MDT meetings
“I am concerned about the CRISIS team MDT meetings and their functionality. It is difficult to understand how a meeting attended by around 7 people agreed a treatment plan which was based upon incorrect information relating to the patient's medication status. This is particularly difficult to understand when the correct medication status is clearly documented in the patient's core assessment paperwork (which was completed by the Liaison Team on 22 November 2021 and sent to the CRISIS Team).”
2. poor and missing documentation of MDT discussions
“I remain concerned about both the standard of documentation and lack of documentation relating to the discussion of Miss [name redacted] at the two MDT meetings. The Trust were only able to provide me with documentation relating to one of the two MDT meetings. That documentation is incorrectly completed and lacks detail. In particular, there is no detail about medication despite there being a specific box within which to document this.”
3. inadequate Serious Incident Investigation processes
“I remain gravely concerned about the inadequacies in the Serious Incident Investigation and Reporting processes at Leicestershire Partnership NHS Trust.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“The Serious Incident Investigation failed to identify the errors in the care provided to Miss [name redacted] making the use of the process somewhat otiose in this case.”
Later report
“The Serious Incident Investigation into Mr [name redacted] death did uncover and accepted some failings in relation to the care provided to Mr [name redacted].”
Responses
2023-0290-Response-from-Leicestershire-Partnership-NHS-Trust.pdf ↗· Leicestershire Partnership NHS Trust
Stated action
“We will capture the learning from this inquest and other SI reports produced by the Trust and will share this learning across the Trust through our learning forums and Quality Improvement Collaboratives.”
Stated action
“The Trust was unable to contact the Locum Consultant for input into the original SI investigation due to not holding the latest contact details; the Locum Consultant was no longer contracted to work with the Trust, and they had left the country.”
Stated action
“We confirm that prior to the MDT meeting, the Locum Consultant accessed SystmOne for a period of seven minutes. We also confirm that they did not raise any concerns regarding MDT meetings with the Clinical or Medical Director.”
Stated action
“We will provide further detail of this MDT meeting in our review of the initial SI report.”
Stated action
“The Serious Incident Investigation failed to identify the errors in the care provided to Miss [name redacted] making the use of the process somewhat otiose in this case.”