Maud Patrick
8 May 2017 · Coroner Nigel Meadows · Manchester (City)
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of mental capacity assessment
“There was no apparent consideration to the issue of whether or not the deceased had mental capacity from admission to A & E and transfer to AMU.”
2. incomplete investigations and handover
“Ensuring all investigations/assessments are completed before a patient leaves A&E and ensuring an appropriate handover. It is appreciated that it will not be possible for all investigations and tests to be performed before a patient leaves the A & E department but if that is the case then the receiving ward should be informed and there should be a clear documented audit trail so that it is clear what is outstanding.”
3. absence of clear handover process
“Transfer and hand over of a patient to AMU from A & E. There was no clear hand over process and review when the deceased arrived on the AMU. It would seem sensible that a Senior Nurse/Sister be informed and can then ensure appropriate care is given.”
4. failure to progress investigations
“Ensuring investigations are progressed as appropriate. There was no progression of necessary basic assessments/tests which remained outstanding. For example, a chest X-ray.”
5. lack of neurological observations
“Ensuring that all neurological and/or general observations are appropriately undertaken, accurately recorded and calculated but also escalated as necessary. It is a fundamental part of basic medical and nursing care that a patient who requires neurological or general”
6. insufficient senior nursing staff
“Staffing levels, competence and seniority. The levels and competence of staff ( whether agency or Trust employees ) needed to deliver safe and appropriate care and with sufficient senior Nursing staff in leadership roles requires assessment and implementation”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records.”
This report
“Transfer and hand over of a patient to AMU from A & E. There was no clear hand over process and review when the deceased arrived on the AMU.”
Closely relatedConfidence 0.80 · moderate
This report
“There was no apparent consideration to the issue of whether or not the deceased had mental capacity from admission to A & E and transfer to AMU.”
Later report
“A mental health liaison nurse, who now is manager of these nurses, did not recognize the patient as high risk, despite his having been persuaded to attend A&E by the police against his will,”
Responses
No published response was found on judiciary.uk.