Mary Nwanonyiri
1 Dec 2022 · Coroner Nadia Persaud · East London
The coroner's concerns
1. lack of agreed comprehensive care plan
“Senior nursing staff who gave evidence at the Inquest did not appear to appreciate the importance of an agreed comprehensive care plan in which the multi-disciplinary ward team, patient and relatives are involved”
2. failure to recognise acute clinical severity
“A number of nurses failed to recognise the acute clinical severity of [the deceased]'s condition on the morning of the 19th April 2021”
Responses
2022-0389-Response-from-North-East-London-Foundation-Trust.pdf ↗· North East London Foundation Trust
Stated action
“The Executive Team currently have oversight of care planning compliance Trust wide.”
Stated action
“The Named Nurse/Health Professional Standard Operating Procedure (SOP) will be amended to make this explicit as it currently states: 'In most cases the named nurse/professional will have an associate who will deputise in his/her absence'.”
Stated action · January 2023
“The January 2023 Respect Approach Meeting will have a specific focus on care planning and the care planning audit tool.”
Stated action
“Resuscitation drills have been increased from every 2 months to monthly for every ward.”
Stated action
“A business case will be submitted to the Executive Management Team for increased capacity for Resuscitation Officers, including a dedicated Resuscitation Officer for ARD.”
Stated action
“The process for auditing the content of our emergency equipment resuscitation trolleys on our wards has been reviewed and is now inputted via the 'my kit check' app.”