Steven Rogers
20 Jan 2016 · Coroner John Pollard · Manchester (South)
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. discharge without assessment
“The doctor who discharged the patient from the hospital as being "medically fit for discharge" did so without ever seeing the patient”
2. insulin omission
“During his stay in the hospital, the staff had erroneously omitted to administer his Levemir long acting insulin”
Linked reports
Identical hazardConfidence 0.95 · high
Earlier report
“ALL the doctors in training need to be aware that they should not omit any dose of 'long-acting insulin'”
This report
“During his stay in the hospital, the staff had erroneously omitted to administer his Levemir long acting insulin”
Responses
Steven-Rogers-Response.pdf ↗· Stockport NHS Foundation Trust
Stated action
“Trust is moving towards a Trust wide electronic patient record (EPR) which should resolve this issue, but in the meantime, | can confirm that there isa specialist "Task& Finish Group" in-place to further review this issue and develop.an effective interim solution. This group reports to the Trust's Risk Management Committee and through this to the Quality Governance Committee and the Quality Assurance Committee, which reports directly to the Board”