08.03.19
Isle of Wight Trust admits ‘failing terribly’ in reports to coroner who was left ‘wanting to weep’
An NHS trust has admitted “failing terribly” in not disclosing abnormalities over the death of patients to the coroner.
Coroner Caroline Sumeray told a hearing that 20 serious incident investigations (SI) were not reported to her by the Isle of Wight NHS Trust (IOW) before the bodies had been cremated.
The chief executive of the trust – which is now in special measures for both quality and finances –Maggie Oldham, was fined £500 by the coroner, and Sumeray said that some staff did not understand the nature of the inquest process.
This comes on the same day that the IOW trust has been placed in financial special measures by NHS Improvement and hit with an urgent performance warning for the quality of care provided at its St Mary’s Hospital.
In one case, the coroner said she “wanted to weep” when she learned in January that an SI investigation was being carried out into a drug-related death, a month after she had closed the inquest.
Sumeray said her “head spun round” when she heard that trust staff had failed to notify her because “they didn't realise that when there was an inquest, that meant that somebody had died.”
In another case, the Isle of Wight coroner said she had signed off the death of a 93-year-old woman before being told an SI was being carried out involving the patients’ mental health and discharge from hospital.
Sumeray said: “In all 20 cases... I have had to metaphorically resurrect the dead.
“The bodies were released and in every single case they were cremated, which causes me a really big problem now because the trust then subsequently informs me that there are serious incident investigations based on information that wasn't referred to me.”
In three cases, deaths were not reported to the coroner at all, and Sumeray said she was “extremely disappointed” and felt like she was letting the office down due to her slow death-to-inquest rate which was actually the result of the trust’s delays.
Earlier today, the CQC issued the trust with a warning notice demanding that it improves the services at its St Mary’s hospital “as a matter of urgency” after inspectors found major issues with low staffing levels and with how and where patients were being assessed.
NHSI also placed IOW NHS Trust into special measures for finances amid a £13m deficit at the trust.
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