Patricia Webb
20 Apr 2017 · Coroner Veronica Hamilton-Deeley · Brighton and Hove
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. falls on Emerald Ward without adequate monitoring
“At the Inquest | was told that on Emerald Ward the Nursing staff have a higher awareness of the risk of falls because so many of their patients are at high risk. However, they provide no specialling. Presumably the rationale for this is that they are extremely good at their job and are able to take care of their patients without specialling. Demonstrably in Mrs [name redacted] case this did not happen”
2. lack of implementation of observation and activity plan
“There was a plan in mid-September put in place by the Dementia Nurse for Mrs [name redacted] to have increased levels of observation, for her to be engaged in meaningful activity and for allowing her to be mobile but using non slip footwear and a mobility aid. With regard to the observations | really could not see any evidence that this was giving her enhanced protection. When analysing the falls and their timing it was clear that they always happened early in the morning and often round about the end of the”
3. inadequate non slip footwear causing fall risk
“Non slip footwear however, is surely much easier to provide. | know that the hospital footwear comprises 'short socklets' in different sizes (thus the right size is always difficult to obtain) with non-slip soles.”
4. reactive fall response system
“In the Royal Sussex County Hospital, | understand there is to be or already taking place a trial of 'buzzer alerts' for Nurses - | am sure this is an extremely good idea but feel that it may be more profitable to be proactive rather than reactive.”
5. inadequate handover documentation
“The final area which concerns me is handover. It is such an important time for exchange of information so that appropriate care can be given to each individual patient and from what | heard at Mrs [name redacted]'s Inquest the handover relies more and more on the notes and the notes are relying more and more on tick boxes which are simply not adequate to deal with the individualities of each patient.”
6. lack of community engagement for resource allocation
“During the course of this Inquest | heard that it was very difficult to obtain extra resources for some of the things which were discussed. | suggested that possibly local appeals could be useful and maybe even an article in the local newspaper engaging the local community in an important Ward given that it deals with many elderly demented patients waiting for discharge to ongoing care within the community.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. | (4) She arrived unkempt”
This report
“handover relies more and more on the notes and the notes are relying more and more on tick boxes which are simply not adequate to deal with the individualities of each patient.”
Closely relatedConfidence 0.90 · high
This report
“handover relies more and more on the notes and the notes are relying more and more on tick boxes”
Later report
“Mr. [name redacted] was due to be discharged on the 4”
Responses
No published response was found on judiciary.uk.