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19 Jun 2019 · Coroner Alison Mutch · Manchester (South)
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of integrated care across health providers
“[name redacted] was discharged directly from the tertiary centre into the community after a prolonged period of care in NICU”
2. absence of single professional oversight of care
“no one health professional had an overview of his health needs and ensuring that support was put in place and appointments were coordinated”
3. insufficient awareness of early health assessments
“lack of understanding about the use and importance of Early Health Assessments amongst community health practitioners”
4. fragmented information sharing across NHS trusts
“lack of a single IT system across NHS trusts meant that information sharing was more difficult”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.”
This report
“The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult.”
Closely relatedConfidence 0.90 · high
This report
“lack of a single IT system across NHS trusts meant that information sharing was more difficult”
Later report
“incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult”
Closely relatedConfidence 0.90 · high
This report
“The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult.”
Later report
“5 NHS Trusts and 3 police forces in different geographic areas had contact with [the deceased] in the final month of his life and each thereby gained some information about the risk to him.”
Responses
No published response was found on judiciary.uk.