Coroners make recommendations to NHS

Coroners make record number of recommendations to NHS

Coroners have issued a record numbers of recommendations to hospitals in order to prevent future patient deaths.

]1 Under rules amended in 2008, coroners can make recommendations to any organisation at the end of an inquest if they feel they might prevent future fatalities Photo: ALAMY
NHS trusts were warned that they must put more staff on duty outside of office hours to ensure safety on the wards, as well as improving communication and note-taking.

Mental health organisations have also been told to do more to care for people likely to self-harm, while sporting bodies have been given suggestions to reduce risk.

The Ministry of Justice, which collates the recommendations made at the end of inquests, said in a new report: “Over a third of reports issued in this period relate to deaths in hospitals.

“This is now an established trend and has consistently been the case since MoJ began reporting.

“These reports frequently identify concerns over policies and practices in relation to note taking, staffing, training, communication and handover and the recording of medications.

“Coroners have reported directly to the Department of Health where they have identified concerns which may have national implications, or they feel information could usefully be disseminated to all NHS Health Trusts.”

Under rules amended in 2008, coroners can make recommendations to any organisation at the end of an inquest if they feel they might prevent future fatalities, and must receive written responses within 56 days.

The latest figures, published on Tuesday, show that coroner in England and Wales issued 233 of these Rule 43 reports between October last year and March 2012, up from 189 in the same period a year earlier.

“This was the highest number of reports issued in any six-month period since MoJ began reporting in July 2008,” the report noted.

Coroners in Cardiff and the Vale of Glamorgan made more recommendations (11) than any other district, followed by Greater Manchester South and West Yorkshire East (10 each).

The warnings were most commonly issued in connection with hospital deaths (88 reports, up from 58 the previous year), followed by road deaths (30 reports) and mental health deaths (27).

Following 10 deaths, coroners warned NHS trusts they risked having dangerously low staffing levels, particularly at evenings, weekends and public holidays.

Coroners in Brighton, Buckinghamshire, Devon, Bristol, Kent, Surrey, Liverpool, Greater Manchester, West Yorkshire and Staffordshire all told the NHS to review the numbers of doctors and nurses on site or on-call.

It comes after a series of reports disclosing that the “nine-to-five” culture in the health service leaves death rates up to 10 per cent higher out of hours.

In addition, 23 reports told hospitals they must record patients’ medical details better and that staff need to improve communication to avoid preventable deaths.

A spokesman for the Department of Health said: “Patients should be able to access expert services seven days a week and they have a right to expect the same level of care on a Saturday or Sunday as they do on a Wednesday.

“Not only would this mean better, safer and more consistent care and treatment, it will also mean better support for junior doctors. We are taking action and working with professional associations to drive this forward across the NHS.

“The Department considers all coroners’ recommendations very carefully and responds to them as soon as possible.”

CREDIT: The Telegraph Daily Newspaper

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