Michael Drewry
28 Dec 2017 · Coroner Andrew McNamara · Nottinghamshire
The coroner's concerns
1. inconsistent continuity of care
“The failure of the Crisis Team to ensure consistency and continuity of care for the deceased, in particular the changing personnel who visited the deceased”
2. inaccurate or delayed records
“The failure of the Crisis Team to make accurate and prompt records of all consultations with the deceased”
3. failure to report or escalate concerns
“The failure of the Crisis Team promptly to report/escalate any matters of concern to senior members of staff so that appropriate and timely steps could be taken in relation to the management of the deceased's care including, if necessary, hospitalisation”
Responses
2017-0386-Response-by-Nottinghamshire-Healthcare-NHS-Trust.pdf ↗· Nottinghamshire Healthcare NHS Foundation Trust
Stated action · early April 2018
“The Trust is shortly to introduce the Modified Modified Continuity Index (MMC) into its routine reporting systems, at both individual and team levels. This is a measure calculated using the total number of patient visits and the number of different clinical staff visiting the patients and gives a resulting score between 0 and 1, the more staff providing care to the patient the lower the score will be.”