YORKSHIRE - EAST, EASTERN, WEST AND WESTERN
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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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1. DEPARTMENT OF HEALTH
2. NATIONAL PATIENT SAFETY AGENCY
Recommendation - Published May 2012
To consider introducing national protocols for the management of medical condition of Medium-Chain Acyl-CoA Dehydrogenase Deficiency.
Letter sent from NALM to Sir David Nicholson, KCB, CBE, Chief Executive, NHS
Click here to download ...
RESPONSE:
From: National Patient Safety Agency
Click here to download ...
MID YORKSHIRE HOSPITALS NHS TRUST
Recommendation - Published May 2012
1. To consider a review of training on the benefits of inducing early births in appropriate cases.
2. To consider whether all Ward Managers should check all Patient Falls flowcharts immediately upon completion, and
staff training on completing such flowcharts.
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
Recommendation - Published May 2012
To consider a review of the methods of opening internal and external doors at the non-secure units at Fieldhead Hospital, Wakefield, to better monitor who is leaving the units.
RESPONSE
From: South West Yorkshire Partnership NHS Foundation Trust
ST. JAMES'S UNIVERSITY HOSPITAL, Leeds
Recommendation - Published May 2012
To consider a review of the role of the Delivery Suite Co-ordinator in taking responsibility for arranging a doctor's review of transfers from the ante-natal ward to the delivery suite, if there are suspicious or pathological traces: undertaking an independent review if a patient with a pathological trace is reported by a midwife and whether doctors reviewing cardiotocography traces should record categorisations.
COMMUNITY HEALTHCARE AND EMERGENCY SERVICES RELATED DEATHS
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NURSING AND MIDWIFERY COUNCIL
Recommendation - Published May 2012
1. To consider asking midwives to emphasise to nursing mothers the importance of staying awake whilst breastfeeding
babies.
2. To consider a review of the information given to parents by nurses and midwives about co-sleeping with their babies.
RESPONSE
From: The Nursing and Midwifery Council
THE ROYAL COLLEGE OF MIDWIVES
Recommendation - Published May 2012
To consider a review of the information given to parents by nurses and midwives about co-sleeping with their babies.
____________________________________________________________________________________
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
________________________________________________________________________________________________________________
1. DEPARTMENT OF HEALTH
2. NATIONAL PATIENT SAFETY AGENCY
Recommendation - Published May 2012
To consider introducing national protocols for the management of medical condition of Medium-Chain Acyl-CoA Dehydrogenase Deficiency.
Letter sent from NALM to Sir David Nicholson, KCB, CBE, Chief Executive, NHS
Click here to download ...
RESPONSE:
From: National Patient Safety Agency
Click here to download ...
MID YORKSHIRE HOSPITALS NHS TRUST
Recommendation - Published May 2012
1. To consider a review of training on the benefits of inducing early births in appropriate cases.
2. To consider whether all Ward Managers should check all Patient Falls flowcharts immediately upon completion, and
staff training on completing such flowcharts.
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
Recommendation - Published May 2012
To consider a review of the methods of opening internal and external doors at the non-secure units at Fieldhead Hospital, Wakefield, to better monitor who is leaving the units.
RESPONSE
From: South West Yorkshire Partnership NHS Foundation Trust
ST. JAMES'S UNIVERSITY HOSPITAL, Leeds
Recommendation - Published May 2012
To consider a review of the role of the Delivery Suite Co-ordinator in taking responsibility for arranging a doctor's review of transfers from the ante-natal ward to the delivery suite, if there are suspicious or pathological traces: undertaking an independent review if a patient with a pathological trace is reported by a midwife and whether doctors reviewing cardiotocography traces should record categorisations.
COMMUNITY HEALTHCARE AND EMERGENCY SERVICES RELATED DEATHS
_________________________________________________________________________________________________________
NURSING AND MIDWIFERY COUNCIL
Recommendation - Published May 2012
1. To consider asking midwives to emphasise to nursing mothers the importance of staying awake whilst breastfeeding
babies.
2. To consider a review of the information given to parents by nurses and midwives about co-sleeping with their babies.
RESPONSE
From: The Nursing and Midwifery Council
THE ROYAL COLLEGE OF MIDWIVES
Recommendation - Published May 2012
To consider a review of the information given to parents by nurses and midwives about co-sleeping with their babies.