Ranjan Mistry
4 Mar 2016 · Coroner John Pollard · Manchester (South)
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of falls risk assessment
“The evidence showed that there was no, or no sufficient, assessment of her Falls Risk.”
2. missing neurological observation charts
“The Neurological observation charts were either never completed or had been lost from the notes.”
3. lack of communication between medical and nursing staff
“There was clear evidence that the medical staff were not reading (or even looking at) the nursing notes, and the nurses were similarly not looking at the medical entries.”
4. destruction of hand-over sheets
“The hand-over sheets for each shift were being shredded by the nurses as soon as the shift was completed. Whilst it is appreciated that these cannot be placed on the record of an individual patient for reasons of confidentiality, there is no reason why they could not be filed on the wards and retained for say 14 days which would allow further reference to be made to them, should this be deemed necessary or helpful.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“There was generally poor communication between nursing and medical staff (inter se) and between medical/nursing staff and the family of the patient.”
This report
“There was clear evidence that the medical staff were not reading (or even looking at) the nursing notes, and the nurses were similarly not looking at the medical entries.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“There was extremely poor communication between hospital staff and the patient (and her family), and between and amongst themselves. There was evidence of a lack of handover between staff, and this was exacerbated by the fact that the medical and nursing notes were frequently inadequate.”
This report
“There was clear evidence that the medical staff were not reading (or even looking at) the nursing notes, and the nurses were similarly not looking at the medical entries.”