Patient death: prescription charts ‘not completed on 15 days’

Coroner says record-keeping failure in case of patient who died following a pulmonary embolism either suggests lack of understanding of nurses’ professional duty to complete important documentation, or that such practice is commonplace

A hospital has been told to urgently address its nurses’ awareness of their duty to ensure documentation is up to date, after staff repeatedly failed to complete prescription charts for a patient who later died following a pulmonary embolism.
An inquest into the death of Vauna Leeming heard she was admitted to Worcestershire Royal Hospital, Worcester, in February 2024 for surgery after a fall at home in which she fractured part of her femur.
Nursing staff failed to complete Ms Leeming’s prescription charts for 15 days
Ms Leeming underwent surgery for the fracture and was recovering, but her condition worsened in March. She experienced a pulmonary embolism and, despite treatment, died in hospital a few days later.
The inquest was told that on 15 of the 46 days between Ms Leeming’s surgery and her death, nursing staff failed to complete prescription charts showing whether compression stockings had been fitted and were being worn, including five consecutive days in one week.
On two days, they also did not complete documentation stating if the patient’s anticoagulation medication, Enoxaparin, had been administered. Both these measures were put in place after Ms Leeming’s surgery to prevent the development of a deep vein thrombosis or pulmonary embolism.
‘It was of particular concern that for five consecutive days, no nurse had noticed or raised with a senior colleague that prescription charts had not been completed to show that compression stockings had been fitted’
David Reid, senior coroner
Prevention of future deaths report – ‘either little understanding of duty, or common practice’
In a prevention of future deaths report to Worcestershire Acute Hospitals NHS Trust (WAHT), which runs the hospital, senior coroner David Reid wrote: ‘It was of particular concern that for five consecutive days, no nurse had noticed or raised with a senior colleague that prescription charts had not been completed to show that compression stockings had been fitted.
‘This suggests either that there is little understanding of a nurse’s professional duty to report such omissions, or that the practice of not checking and completing such important documentation is commonplace.’
The inquest also heard evidence that while the trust emphasises the importance of completing documentation during inductions for new nurses, its staffing is ‘heavily’ reliant on agency nurses, who are not expected to be given an induction. It is unclear whether it was agency or employee nurses who failed to complete Ms Leeming’s charts.
Concerns about ‘insufficient awareness’ regarding documentation
Mr Reid highlighted concerns about ‘insufficient awareness’ among the trust’s nurses of their professional duty to complete important documentation and report to a senior colleague any instances where such documentation had not been completed.
WAHT chief nursing officer Sarah Shingler said: ‘I would like to offer my deepest condolences to Ms Leeming’s family and apologise to them unreservedly for the failings in the care she received from us.
‘We have carried out a thorough investigation to identify any learning and taken a number of immediate actions as a result, including developing a plan to address any knowledge or skill gaps – particularly around the importance of accurate documentation and clinical record-keeping.’
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