“The inquest heard evidence that communication between clinicians and the nursing team on…”

The coroner’s concerns

– 1. The inquest heard evidence that communication between clinicians and the nursing team on the neurosurgical ward was not effective. The teams appeared to operate in silos and key information about patients did not appear to have been shared between the teams; 2. Documentation (clinical and nursing) was incomplete and did not detail key/important information about Rhys. This included ward round notes containing limited information which meant it was difficult to know what matters had been considered as part of discharge planning and what information was known to the clinicians; 3. THE VTE policy was not fully followed and there was evidence that there was limited understanding by staff of precisely what the trust policy required in relation to reducing the risk at discharge of VTE; 4. Despite a critical medicine being not given to Rhys there appeared to be no clear policy on how that would be escalated to a senior nurse/ treating clinician and how that escalation would be captured in the notes; 5. The evidence was that the system and responsibility between the hospital pharmacy and clinicians for reconciling medications given in the community with those given in the hospital to ensure all necessary medications were given was unclear. As a consequence, Rhys did not receive his ADHD medication; 6. There appeared to be limited understanding amongst the nursing team of when a hospital “passport” system should be instigated for someone who was admitted with a “passport”; 7. The system for deciding when a discharge form the neuro surgical ward was safe was unclear. The evidence appeared to suggest that the Physiotherapy team took responsibility for it if they assessed mobility at a suitable level. It was unclear how that was overseen and fitted with the responsibility of the treating clinician; 8. The VTE policy of the trust is based on the NICE guidance. The inquest identified that there is a difference in approach on the use 2 of prophylaxis for a surgical bariatric patient and a neuro surgical patient. Where there is a bariatric patient who is a neuro surgical patient there does not appear to be any clarity on how the challenges should be approached to reduce the risk of VTE as far as possible.

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, 2024-0021

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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