Patricia Catterall
11 Apr 2025 · Coroner John Gittins · North Wales (East and Central)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inadequate transfer assessment
“the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed prior to the patient being received into their care”
2. reduced monitoring of blood sugar
“the deceased's blood sugar levels were monitored three times per days whilst in the care of Health Board.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The Health Board's Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur.”
This report
“That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed”