CORNWALL
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If the Coroner feels that evidence gives rise to a concern that circumstances creating a risk of other deaths will occur or continue to exist, he/she may make a Rule 43 report which is sent to the organisation that has responsibility for the circumstances. A recipient of a Rule 43 report must send a written response within 56 days to the Ministry of Justice.
The Coroner has sent a Rule 43 to the following organisation/s ...
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HOSPITAL DEATHS: CLINICAL PROCEDURES AND MEDICAL MANAGEMENT
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ROYAL CORNWALL HOSPITALS NHS TRUST
Recommendations - Published May 2012
To consider a review to improve the monitoring of patients: the accurate recording of observations: the completion of medical records and improving communication between medical and nursing staff.
MENTAL HEALTH RELATED DEATHS
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1. SULLIVAN CUFF SOFTWARE LIMITED
2. ROYAL CORNWALL HOSPITALS NHS TRUST
Recommendation - Published May 2012
Sullivan Cuff Software to provide an explanation of their procedures, reporting and audit processes for the use of INRstar for initiating the anti-coagulation process, including enquiries made when a patient dies:
Royal Hospitals to consider a review of staff awareness of the appropriateness of using INRstar for initiating the anti-coagulation process, and the reporting and auditing procedures following an untoward incident.
_______________________________________________________________________________
If the Coroner feels that evidence gives rise to a concern that circumstances creating a risk of other deaths will occur or continue to exist, he/she may make a Rule 43 report which is sent to the organisation that has responsibility for the circumstances. A recipient of a Rule 43 report must send a written response within 56 days to the Ministry of Justice.
The Coroner has sent a Rule 43 to the following organisation/s ...
______________________________________________________________________________________________________________________________
HOSPITAL DEATHS: CLINICAL PROCEDURES AND MEDICAL MANAGEMENT
________________________________________________________________________________________________________________
ROYAL CORNWALL HOSPITALS NHS TRUST
Recommendations - Published May 2012
To consider a review to improve the monitoring of patients: the accurate recording of observations: the completion of medical records and improving communication between medical and nursing staff.
MENTAL HEALTH RELATED DEATHS
________________________________________________________________________________________________________________
1. SULLIVAN CUFF SOFTWARE LIMITED
2. ROYAL CORNWALL HOSPITALS NHS TRUST
Recommendation - Published May 2012
Sullivan Cuff Software to provide an explanation of their procedures, reporting and audit processes for the use of INRstar for initiating the anti-coagulation process, including enquiries made when a patient dies:
Royal Hospitals to consider a review of staff awareness of the appropriateness of using INRstar for initiating the anti-coagulation process, and the reporting and auditing procedures following an untoward incident.