Wirral
Coroner Area
Reports: 3
Earliest: May 2014
Latest: 8 Jun 2014
James McArdle
All Responded
2014-0264
8 Jun 2014
Arrow Park Hospital NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The withdrawal of a coloured wristband system for falls risk without replacement removed a vital protection, increasing the risk of falls for elderly patients.
Action Planned
(AI summary)
The Trust is developing a new policy specific to patient falls, providing clearer guidance on risk assessments and timescales, and will communicate changes to nursing staff and revise audit questionnaires to monitor compliance.
Jennifer Morrison
All Responded
2014-0265
2 Jun 2014
Arrowe Park Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to prolonged assessment unit stays and treatment delays.
Action Taken
(AI summary)
Wirral University Teaching Hospitals NHS Foundation Trust describes measures to manage medical records, including a Health Records Management Policy and regular audits. The Surgical Division now holds daily management meetings to review staffing levels, and the Surgical Assessment Unit (SAU) underwent a 'Listening into Action' project, increasing junior doctor presence, introducing consultant rounds, and regular staffing reviews.
Samarjit Singh
Partially Responded
2014-0239
23 May 2014
Department of Health and Social Care
NHS England
Wirral Clinical Commissioning Group
Mental Health related deaths
Concerns summary (AI summary)
The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in sub-optimal treatment and declined referrals for mothers with severe postnatal depression.
Noted
(AI summary)
NHS Wirral CCG established a working group to review the perinatal mental health pathway. They are revising the Liaison Psychiatry service specification to include dedicated consultant psychiatrist time and requiring specialist staff in the new IAPT specification due to start in April 2015. The Department of Health acknowledges the coroner's concerns regarding perinatal mental health services in the Wirral and Liverpool. They state that commissioning of local services is the responsibility of Clinical Commissioning Groups and that regional mother and baby units are sufficient, but will raise awareness with CCGs.