Brighton & Hove

Coroner Area
Reports: 61 Earliest: Feb 2014 Latest: 15 Jul 2021

70% response rate (above 63% average).

Response Status
Responded 43 Historic 18
AI Classification
Action Taken 56%
Action Planned 31%
Noted 10%
Disputed 4%
Based on 52 classified responses
Top Categories
Hospital Death (Clinical Procedure… (46) Mental Health related deaths (5) Alcohol, drug and medication relat… (5) Community health care and emergenc… (4) Police related deaths (4)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South East average: -21 reports · +10pp response rate
vs national average: -23 reports · +7pp response rate
Clear 33 results
Alice Mead
All Responded
2015-0239 24 Jun 2015
Sussex Partnership NHS Foundation Trust
Suicide (from 2015)
Concerns summary (AI summary) Significant failings in mental health care involved the absence of a care coordinator, ignored patient requests for medication review, and an unacceptably delayed, "hands off" response to urgent concerns for a vulnerable patient.
Action Taken (AI summary) Sussex Partnership NHS Trust implemented an improved system for reviewing care coordinator caseloads, especially when a care coordinator leaves. Staff in East ATS and MHRRS have undergone Applied Suicide Intervention Skills Training (ASIST), and a new approach to calls is underway in East ATS.
Isaac Bahar
All Responded
2015-0229 15 Jun 2015
Brighton and Sussex University Hospital…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.
Action Taken (AI summary) Brighton and Sussex University Hospitals Trust has discussed the incident with general surgeons and the nursing and pharmacy teams, leading the general surgeons to decide that codeine should no longer be routinely available for them to prescribe.
Evelyn Kennedy
All Responded
2015-0178 7 May 2015
Brighton and Sussex University Hospital…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, unremoved IVs, incomplete care documentation, development of pressure damage, and unescalated NEWS scores indicating clinical deterioration.
Action Taken (AI summary) The Trust has been undertaking work, including improved consultant cover, a working group to address practices and documentation, developing specialist areas, improving signage, improving information handover, and increased monitoring of documentation.
Bruce Longden
All Responded
2015-0149 21 Apr 2015
Brighton and Sussex University Hospital… Sussex Partnership
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.
1 response from Response Brighton and Sussex University Hospitals NHS Trust
Maureen Ellett
All Responded
2014-0473 31 Oct 2014
Brighton and Sussex University Hospital… Royal Sussex County Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from the front sheet.
Action Taken (AI summary) Agreement has been reached with SECAMB that they will start calculating National Early Warning Scores (NEWS) and the triage nurse will note this when the patient arrives. The Trust is continuing to educate staff about avoiding the term 'Acopia'. Individual named emergency consultants have recently been given responsibility for each of the Short Ward and Clinical Decisions Unit.
Martin Hill
All Responded
2014-0382 22 Aug 2014
Brighton and Sussex University Hospitals
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) No specific concerns were detailed in the provided text for this report.
Action Taken (AI summary) The Trust has begun a high-risk review into the death and is improving electronic reporting systems by utilizing a system called "Order Comms" for radiology. The Matron for the CDU has ensured that the staff are familiar with the responsible flowchart. The process for discharge summaries with patients from the CDU is currently under review and it is anticipated that the CDU will soon be utilising the electronic discharge summary process.
Danuta Corbett
All Responded
2014-0150 3 Apr 2014
Sussex Partnership NHS Foundation Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical safety failures.
Action Taken (AI summary) The consultant psychiatrist now carefully reviews notes taken during ward review. The Trust has reinforced with staff that should extraordinary circumstances arise again, a retrospective note must be completed, and the nurse responsible will ensure proper handovers take place in the future.
Graham Watts
All Responded
2014-0149 3 Apr 2014
Brighton and Sussex University Hospital… Royal Sussex County Hospital Princess Royal Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically unfit patient.
Action Taken (AI summary) A social worker has started attending daily "Board Round" meetings to assist in patient discharge planning. The Trust acknowledges shortcomings in the discharge planning process and is aiming to start a one year pilot scheme to focus on consistent multi-disciplinary management of frail elderly patients, in preparation for their discharge.