Jean Waghorn
PFD Report
Historic (No Identified Response)
Ref: 2019-0361
Coroner's Concerns (AI summary)
There were unnecessary and inappropriate transfers between hospitals, and the Brighton and Sussex University Hospital NHS Trust policy for transfer was effectively ignored, despite previous regulation 28 reports concerning the Transfer Policy.
View full coroner's concerns
(1) Unnecessary and inappropriate transfers between the Royal Sussex County Hospital, the Princes Royal Hospital and the Royal Sussex County Hospital.
(2) The Brighton and Sussex University Hospital NHS Trust policy for transfer was effectively ignored. (3) have made two recent previous regulation 28 reports concerning the Transfer Policy on 12 July 2018 and 20 July 2018. The response to the former included the assurance that a trust wide transfer policy working group was convened, led by three extra assessment tool sheets were created. None of these were used for Mrs Waghorn. Why not? What is the point of the Regulation reports if the trust ignores them?
(2) The Brighton and Sussex University Hospital NHS Trust policy for transfer was effectively ignored. (3) have made two recent previous regulation 28 reports concerning the Transfer Policy on 12 July 2018 and 20 July 2018. The response to the former included the assurance that a trust wide transfer policy working group was convened, led by three extra assessment tool sheets were created. None of these were used for Mrs Waghorn. Why not? What is the point of the Regulation reports if the trust ignores them?
Sent To
- Brighton and Sussex University Hospital NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
3 Feb 2020
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 1st July 2019 | commenced an investigation into the death of Jean Evelyn WAGHORN The investigation concluded at the end of the inquest on 15th October; 2019.The conclusion of the inquest was a Narrative Conclusion: - Mrs. WAGHORN died of pneumonia which developed when she was in hospital receiving conservative care for fractures to her neck sustained when she fell at home and hit her head on the floor: This lady was transferred between hospitals three times in just over 48 hours. FIND that the first transfer late on 23rd June 2019 (the of her fall) was appropriate she had been diagnosed with a fractured neck at Haywards Heath Local hospital and needed assessment and care at the South East Trauma and Spinal Centre in Brighton: FIND that the next two transfers were_not appropriate cannot say that they City City day
VERONICA HAMILTON-DEELEY DL,
VERONICA HAMILTON-DEELEY DL,
Circumstances of the Death
Record of Inquest
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you AND your organisation have the power to take such action:
Copies Sent To
See days
VERONICA HAMILTON
DEELEY DL
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.