“During the Inquest evidence was heard that i”

The coroner’s concerns

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- 1. During the Inquest evidence was heard that i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23” April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26 April 2015, nor the attendance off on the 27" April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28" April 2015, even though the family expressed concerns with regard to abdominal pain on the 23" April 2015. ii. | There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26" April 2015. iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26™ April 2015. iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27" April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to taker the actions and a timescale in relation to the actions. The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi- Disciplinary Team Meeting. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms. 2. I request you to consider the above concerns and to carry out a review with regard to the following:- iii. The quality of the notes made by nursing and medical staff at Darley Court Intermediate Care Centre. Liaison between the nursing staff and members of the medical team in relation to patients, particularly in relation to symptoms observed by health professionals and members of the family. The system of handovers, particularly with regard to passing information between healthcare professionals at the end and the commencement of a shift. The conduct of Multi-Disciplinary Team Meetings, particularly with regard to notes to refer to those present, actions to be taken, the person allocated to take the actions and a timescale in relation to such actions. The training of all healthcare professionals at Darley Court Intermediate Care Centre in relation to the above matters.

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judiciary.uk, Prevention of Future Deaths reports

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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