“ore as folows, ~ ‘The Hospital Trust's internal report revealed a number of matters of…”

The coroner’s concerns

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ore as folows, ~ ‘The Hospital Trust's internal report revealed a number of matters of concern in respect ‘of which this reports written, (1) The handover process between shifts was expressed to be different throughout the hospital on different wards. This potentially leads to inconsistency with inadequate Information being shared. ‘twas not clear whose responsibilty it was to ensure that the handover was ‘undertaken in full and thorough fashion. ‘The highlighting ofthe needs of particular patients who wete the subject of the handover was inadequate. | invite the Trust to consider standardising the handover process across the hospital and to put In place a protocol whereby the identity of the person responsible for ensuring the handover takes place is clearly recognised (2) The absence of a sentor review of patients over the weekend was 2 factor in the suboptimal care given to this patient. | invite the Trust to putin place a requirement that all complex cases who are admitted inte the ward on Friday or over the weekend, particularly where they have undergone invasive procedures, are routinely subject to a senior doctor review. (3) There was an acknowledgement within the Trusts investigation that, during the crisis period of this patient's admission there was a lack of leadership from both clinicians and nurses with no ane taking responsibilty to ensure that tests and inveshgations were in fact carried out and followed up. | invite the trust to consider a protocol to ensure that in such situations thera is a nominated individual to take the lead and to ensure optimum care is given. 4 Tha case notes and médical records were (again) inadequate, | have been told on many occasions that the importance of good record-keeping is emphasised to clinicians - Sadly in this case yet again the lessons do not appear te be being learned. | invite the Trust to put in place additional training so that record-keeping is consistent, complete and clear

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2017-0309

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0