Rowan Thompson
1 Nov 2022 · Coroner Joanne Kearsley · Manchester North
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of rigour in audit of observations and documentation
“System by which observations and documentation are audited lacks rigour and is ineffective”
2. missed opportunity for management to understand the gravity and nature of the situation
“missed opportunity for management to understand the gravity and nature of the situation”
3. staff failure to complete observations or falsify records during night shift
“Whether the staff who failed to complete observations/falsify records did so when working a particular shift ie night shift”
4. staff failure to complete observations or falsify records during weekend
“Whether the staff who failed to complete observations/falsify records did so when working weekends rather than during the week”
5. correlation between missed observations or falsifying records and absence of deputy or ward manager
“Whether there was any correlation between missed observations / falsifying of records and shifts when there was no deputy or ward manager on duty”
6. inexperienced staff in charge on 3rd October 2020
“experience of the staff in charge on the 3rd October 2020 was a concern”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“There was no robust audit system for checking compliance with the Trusts own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.”
This report
“System by which observations and documentation are audited lacks rigour and is ineffective.”