Susan George
29 Feb 2016 · Coroner Lisa Hashmi · Manchester (North)
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. discharge without review
“No review of the decision to discharge was sought or conducted when it became apparent that there had been a material change in [the deceased]'s presentation on the 10th November. Had a review taken place then it is likely that the discharge would have been deferred or cancelled.”
2. disjointed discharge process
“The discharge process was disjointed, lacked co-ordination and did not involve [the deceased]'s Primary/Associate Nurse.”
3. perfunctory discharge policy
“The Discharge Policy was perfunctory and staff failed to follow it in any event.”
4. poor record keeping
“Poor record keeping, predominantly on the part of the nursing staff.”
5. absence of emergency contact protocol
“There is no protocol/guidance on what steps should be taken when an inpatient contacts the emergency services (e.g. police via 999).”
6. unprofessional staff attitudes
“Unprofessional staff attitudes towards patient/care provision - two qualified nurses involved in [the deceased]'s care used inappropriate language and demonstrated negative ways of thinking during both conversations with colleagues and the police communications operator.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“That the GP's recollection of events was not supported by contemporaneous record keeping, thus calling into question accuracy.”
This report
“Poor record keeping, predominantly on the part of the nursing staff.”
Closely relatedConfidence 0.90 · high
This report
“Poor record keeping, predominantly on the part of the nursing staff.”
Later report
“There was evidence to show that record keeping was poor and at some points non-existent.”
Closely relatedConfidence 0.80 · moderate
This report
“No review of the decision to discharge was sought or conducted when it became apparent that there had been a material change in [the deceased]'s presentation on the 10th November.”
Later report
“A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided.”
Responses
Susan-George-Response.pdf ↗· Pennine Care NHS Trust
Stated action
“The discharge assessment document is prepared prior to planned discharges and is then completed on the day of discharge by the discharge nurse. The final page of this document is the 'Discharge Plan' which contains the emergency contact numbers and a crisis contingency plan. A copy of this is handed to the patient upon discharge.”