William Simons
4 May 2021 · Coroner John Ellery · Shropshire, Telford and Wrekin
The coroner's concerns
1. confusion and breakdown in communication
“It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it. b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly. c) The system on the day led to”
2. unclear porter responsibilities
“It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available.”
3. lack of fall risk awareness
“The porter did not know the patient's level of risk of falls.”
Responses
2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted.pdf ↗· Shrewsbury and Telford Hospital NHS Trust
Stated action
“Taken: The mode of transport to the department for the investigation for an inpatient is specified on the form by the doctor making the request. This should be done in discussion with the nursing staff. However, the patient's condition may change from the time of the request to the investigation being undertaken and so a further assessment should be made by the registered nurse (RN) caring for the patient at the time of transfer of the patient. When Mr [name redacted] was going for his investigation, it was”
Stated action · 12 May 2021
“As part of the response to the Regulation 28 this has been recommunicated across the Trust via: - Trust wide safety alert (attached) - A discussion at a Ward Manager's meeting with the Director of Nursing on 12 May 2021 to ensure that a Nurse (either a Registered Nurse or a Healthcare Assistant) always assists the Porter with the transfer of the patient on their return to the ward from another department”
Stated action
“taken: Falls awareness training is currently being delivered by the Falls Practitioner to all Portering staff. This training includes making Porters aware of visual alerts that patients at risk of falls have in place, for example yellow wrist bands and icons both at their bed space and on the patient safety screens near the nurses' station. The expectations around undertaking falls awareness training for Porters will be included in the Procedure for Managing Inpatient Falls. This training will now be”