“(brief summary of matters of concern) 1”

The coroner’s concerns

(brief summary of matters of concern) 1. In evidence I was advised during Mrs McCreadie's stay in hospital her dietetic needs were not addressed as there was insufficient staffing in the dietician department. I asked the hospital when giving evidence if these issues had been addressed and was advised that there were still ongoing. I am concerned that if appropriate staffing levels are not put in Regulation 28 – After Inquest Document Template Updated 30/07/2021 place, patient's needs will not be met. 2. During evidence I was advised that a training need had been identified for staff regarding pressure sores following the passing of Mrs McCreadie. I have been advised in submissions by the hospital that they intend to address this training need by identifying elearning staff can complete. Given in evidence it was identified that a) some staff do not know how to support and or handle patients who are in pain and refuse to be repositioned; and b) the staff are unaware of the techniques needed to be used to reposition patients who have multiple injuries, I do not consider that these can be adequately addressed by elearning. 3. During the doctor's evidence, at inquest, an issue was highlighted regarding ordering of fortsips on the hospital computer system, a dietary supplement. An order had been made to be started on 10th May to 3rd June twice daily. This was not processed. I was advised in evidence by the hospital that the doctor could be shown how to release it. However, there is no evidence as to how this error could be identified if it should reoccur and a clinician was not aware that the order for fortsips was not released on the system. 4. At the time of the inquest, I was informed during Mrs McCreadie's stay a number of staff were agency staff. I note that the hospital now have more permanent staff in place on the ward than when Mrs McCreadie was on the ward. I remain concerned that agency staff who may still need to be called to assist on the ward may not have sufficient training on the computer system used for recording medical care provided before they are required to do so whilst working on the ward. At the inquest there was evidence that insufficient training had been given and therefore there were inconsistencies in recording of treatment given or needed. I understand permanent staff receive 9 hours of training, whereas agency staff may receive only up to 1 hour of training.

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, 2024-0300

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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