Terence O'Connell
28 Aug 2013 · Coroner Louise Hunt · Bridgend, Glamorgan Valleys & Powys
The coroner's concerns
1. communication breakdown between care home district nurses and out of hours GP
“There was a communication breakdown between the care home, district nurses and _ | out of hours GP on the 3% May 2013 resulting in Mr [name redacted] not being seen by any __ clinical staff”
2. lack of direct monitoring of oral input and urinary output
“There was no direct monitoring of his oral input and urinary output at the care home which would have provided further evidence in support of a urinary tract infection.”
3. lack of clinical assessment for 2 days
“Mr [name redacted] did not have any clinical assessment of his condition for 2 days until his admission to hospital”
Responses
2013-0218-Response-by-Gabbandco.pdf ↗· ABMU Health Board
Stated action
“the Monkstone House policy has now been changed with regard to clinical assessment. The effect of this is that if a health professional (either district nurse or GP) will not attend Monkstone House within one hour of being called, the patient will be sent to the local A&E Department.”
2013-0218-Response-by-University-Health-Board.pdf ↗· ABMU Health Board
Stated action · October 2013
“The Health Board has implemented a clear and accurate message sheet, SBAR (Situation, Background, Assessment, Recommendation), for the switchboard staff at the Princess of Wales Hospital to record all out of hours requests for District Nurses in greater detail. The SBAR forms will ensure clear, audible records of referrals to the District Nursing Service in the Bridgend Locality, supporting safe, high quality patient care and the ability to review information and audit.”