My dad went in to hospital with a chest infection.

he was on special measures .

he was going home

just before Christmas got a call to say my dad had taken a turn for the worse 2am.

when my brother got there my dad had an almighty bump and bruise on his fore head.

.when asked what had happened to him

first nurse said he bumped his head on the hospital side head board

.then we were told he pulled the tv on his head.

i called the coroner the next day so my dad could have an autopsy as we were not satisfied

After the autopsy the pathologist said he died as a direct result of a head injury.

an inquest was due 3 months after his death,

then a letter from the coroner to say due to no fault of theirs it has been cancelled till the 30th October nearly a year

have just been told that the hospital have lost his notes

What is our position now

any one can advise before we go to the inquest please

that is the point of the inquest,

to inquire and hopefully translate this into something useful to prevent other deaths.

You know why it has been postponed so you should be making sure that you have suitable reminders to make sure that the right questions are asked and answered.

If the notes are still msiing you need ask the coroner to consider inferring the worst from this.

What worries me about everything being put on a database rather than written notes

is that it is easy to alter the netires and unless you can get at the metadata you wont know what has been altered, when and by whom.

If I were a suspicious person

I would think that the hospital trust has been advised by its solicitors to delay things whilst his notes are gone through to edit them down to the minimum as far as exposure to a legal claim goes

you may need to find out who the staff in the ward were,

which doctors looked at him at any point of his stay etc

so you can be sure that all of their reports are included.

Problem then is they think that you are going to sue so try even harder to minimise what is said.

that is the world we live in,

they wont apologise because that will be seen as an admission of culpability

and the lack of apology then makes the aggrieved more determined to chase it up

Sounds fishy to me!!!

Have you got your own solicitor?

I feel you need them and not a forum on the internet

Eric’s Brother, I can tell you from first hand experience that electronic notes aren’t easily edited. On the odd occasion I’ve had to do this because of an incorrect entry (details added onto a patient they don’t relate to etc) the process and audit trail is a mile wide. The entry itself remains and is marked and discounted from further usage.

In reality a paper record would be far more likely to be edited without any evidence being left.

OP, if you’re concerned about potential edits then ask for the audit trails to be provided too. They’ll show every interaction with the records in the finest detail.

Altering paper notes isn’t easy, either.

Where an error needs to be corrected the aberrant entry should be crossed through (BUT left legible), and annotated with time & date of correction (together with e.g. “see 3 sides forward”).

“Tippex” and obliterating entries is a no-no.

As it is rare for one person’s entries to fill one sheet, there is usually someone else’s entry on any given sheet, so substituting a sheet isn’t easy.

Single sheets might “go missing”, but this would usually be detectable by “the gap”.

A whole file can go missing but I wouldn’t immediately ascribe this to malice.

It is usually because someone has it (because it is a Mexico-legal issue!), and the “tracing” system hasn’t worked.

The notes then “reappear” at some random time and place when they get returned to storage / someone realises the tracing is wrong / Someone’s desk gets tidied!

Have they sent out an “all users” message asking if anyone has them / has seen them? Have the checked with the “last user they were signed out to” that they haven’t been sent (for legal advice / an expert opinion) and erroneously marked as “sent back to medical records”.

Only copies should be provided to experts / the lawyers, but you’d be surprised ....

That adds another option : were copies taken eg for legal opinion?

If so the copies themselves might be copied .....

The bottomless pit that is the Consultants out-tray...

My dad went in to hospital with a chest infection.

he was on special measures .

he was going home

 

just before Christmas got a call to say my dad had taken a turn for the worse 2am.

 

when my brother got there my dad had an almighty bump and bruise on his fore head.

.when asked what had happened to him

first nurse said he bumped his head on the hospital side head board

.then we were told he pulled the tv on his head.

 

i called the coroner the next day so my dad could have an autopsy as we were not satisfied

After the autopsy the pathologist said he died as a direct result of a head injury.

an inquest was due 3 months after his death,

 

then a letter from the coroner to say due to no fault of theirs it has been cancelled till the 30th October nearly a year

 

have just been told that the hospital have lost his notes

 

What is our position now

 

any one can advise before we go to the inquest please

So there are two different accounts to how your dad received his head injury according to hospital.

Did anyone apart from your brother hear or witness the first nurse stating he had bumped his head on hospital side board??

And how longer after that claim was it alleged your dad pulled a tv on his head?, again where there witnesses to this allegation.

Were Health and Safety informed?? after the accident, do you know.

Ahh, but the Secretary has power over it once it reaches the out tray.

“In-tray” issues and “pending” issues are more common than “out-tray” problems, unless (bearing in mind today’s NHS) :

There is no secretary. There was, but they left /retired and they weren’t replaced (or roles got amalgamated!).

Then the out-tray issue bites with a vengeance.

So there are two different accounts to how your dad received his head injury according to hospital.

 

Did anyone apart from your brother hear or witness the first nurse stating he had bumped his head on hospital side board??

 

And how longer after that claim was it alleged your dad pulled a tv on his head?, again where there witnesses to this allegation.

 

Were Health and Safety informed?? after the accident, do you know.

Most Trusts use Datix (or equivalent) for “incident reporting”. (Even if it isn’t Datix - the firm, it is sufficiently common to be referred to : a bit Like “Hoover” for “vacuum cleaner” or “Jaccuzi” for “spa bath”)

This might be a useful adjunct / alternative if the notes remain AWOL.

It would be deemed an event rather than an incident if someone has died from the injuries sustained.

Police and health and safety surely should have been involved, if they were not,.....

If the police were called to every “event” / incident in a hospital where someone MIGHT die : they’d have a station within every hospital.

“Health & Safety”: do you mean the patient safety team in the hospital (who probably would have been involved), or the HSE?

“Ahh, but what about where someone has died?”, I hear you ask.

Death should be reported to the Coroner (their officer, in practice), who decides if the police should investigate.

No I am not saying that the police or health and safety should be called someone dies in a hospital, but when someone goes into hospital with a chest infection but dies from something unrelated to what they were in there for, in the first instance, you are evidently missing that point.

Are you saying that because the man went in with a illness that the hospital have said themselves was not the cause of death, because he is in a hospital that makes it ok, do????

Police should have been involved and if patients are able to pull TV's down on top of their heads, which is very unlikely, Health and Safety should have been involved because hospitals like most places where there are TV's are, should and never would be designed to pull down.

Anyone has the right to report a suspected death to the police, not just certain individuals like coroners as you have suggested.

If the police were called to every “event” / incident in a hospital where someone MIGHT die : they’d have a station within every hospital.

“Health & Safety”: do you mean the patient safety team in the hospital (who probably would have been involved), or the HSE?

 

“Ahh, but what about where someone has died?”, I hear you ask.

Death should be reported to the Coroner (their officer, in practice), who decides if the police should investigate.

No I am not saying that the police or health and safety should be called someone dies in a hospital, but when someone goes into hospital with a chest infection but dies from something unrelated to what they were in there for, in the first instance, you are evidently missing that point.

I wasn’t saying “all deaths in hospital”, but ones where there had been an incident / event.

If the death was due to something other than the patient’s naturally occurring illness then it should be reported to the coroner.

It seems this happened (either by the hospital or the family, but probably the hospital, since the OP didn’t say “AND we had to inform the coroner because the hospital wouldn’t”).

If the hospital thought there was malice or negligence to the criminal standard they should inform the police.

Otherwise: the Coroner.

Are you saying that because the man went in with a illness that the hospital have said themselves was not the cause of death, because he is in a hospital that makes it ok, do????

Where have I said it is OK?

Police should have been involved and if patients are able to pull TV's down on top of their heads, which is very unlikely, Health and Safety should have been involved because hospitals like most places where there are TV's are, should and never would be designed to pull down.

See above. I’m still not clear if you are saying “the HSE” or “patient safety team in the hospital”.

Anyone has the right to report a suspected death to the police, not just certain individuals like coroners as you have suggested.

Where have I suggested “just certain individuals”?

Such deaths should be reported to the Coroner. The hospital or the family can certainly involve the police (& should if there are concerns of malice).

The police would establish if there were concerns of malice or negligence of an individual (which can occur by a breach of duty of care), whereas for corporate manslaughter there would have to be concerns of a “gross breach” of duty of care.

So, the hospital should report deaths such as this to the Coroner, and may have.

The hospital or family could report it to the police, but unless there is concern of malice, manslaughter by an individual, or corporate manslaughter (including the “gross breach”) the police will either divert it to the coroner’s officer, or start to investigate it until the point where it gets passed to HM’s coroner.

If the Coroner has concerns they can pass it to / pass it back to the police.

Remind me : bearing all that in mind, why does every death where someone has suffered an accident / incident / event need to be passed to the police? Is that really what you are suggesting?.

Its up to the coroner to establish cause of death. If suspicious then its refered. It does sound like the hospital is stalling

The inquest (and thus the coroner or the jury empanelled by the coroner) aim to identify the deceased, determine when and where they died, and determine how they came by their death.

In particular, they do not allocate blame (although it might be inferred from their findings, especially if there is a ‘narrative verdict’).

I wasn’t saying “all deaths in hospital”, but ones where there had been an incident / event.

If the death was due to something other than the patient’s naturally occurring illness then it should be reported to the coroner.

It seems this happened (either by the hospital or the family, but probably the hospital, since the OP didn’t say “AND we had to inform the coroner because the hospital wouldn’t”).

If the hospital thought there was malice or negligence to the criminal standard they should inform the police.

Otherwise: the Coroner.

 

Where have I said it is OK?

 

See above. I’m still not clear if you are saying “the HSE” or “patient safety team in the hospital”.

 

Where have I suggested “just certain individuals”?

Such deaths should be reported to the Coroner. The hospital or the family can certainly involve the police (& should if there are concerns of malice).

The police would establish if there were concerns of malice or negligence of an individual (which can occur by a breach of duty of care), whereas for corporate manslaughter there would have to be concerns of a “gross breach” of duty of care.

 

Sthe hospital should report deaths such as this to the Coroner, and may have.

The hospital or family could report it to the police, but unless there is concern of malice, manslaughter by an individual, or corporate manslaughter (including the “gross breach”) the police will either divert it to the coroner’s officer, or start to investigate it until the point where it gets passed to HM’s coroner.

If the Coroner has concerns they can pass it to / pass it back to the police.

 

Remind me : bearing all that in mind, why does every death where someone has suffered an accident / incident / event need to be passed to the police? Is that really what you are suggesting?.

No you have wrongly suggested that it could only be the coroner who could report matters, correct, yes, thought so, that's wrong, and you also suggested that all hospitals should have stations, again,

Cut to the chase but for the OP brother seeing the damage that caused his brothers death the coroner and the hospital would not have even mentioned this, hence why they seem to be reluctant now to provide here and now.

You seem to live in this wondefull world BarryS that anyone remotely important or has a degree in some subject and for what its worth do no wrong in the real world, nonsense.

Police should have been called and if the hospital are claiming it was because an accident, hence why they and not the OP or his brother should be looking at that, the hospital is digging itself a big hole.

The inquest (and thus the coroner or the jury empanelled by the coroner) aim to identify the deceased, determine when and where they died, and determine how they came by their death.

In particular, they do not allocate blame (although it might be inferred from their findings, especially if there is a ‘narrative verdict’).

You might want to go through this again, you are now saying a coroner has not got the authority nor the power or can they allocate blame, YES THEY CAN.

No you have wrongly suggested that it could only be the coroner who could report matters,

Where did I suggest that, then?

The inquest (and thus the coroner or the jury empanelled by the coroner) aim to identify the deceased, determine when and where they died, and determine how they came by their death.

In particular, they do not allocate blame (although it might be inferred from their findings, especially if there is a ‘narrative verdict’).

You might want to go through this again, you are now saying a coroner has not got the authority nor the power or can they allocate blame, YES THEY CAN.

http://www.independent.co.uk/news/uk/what-is-an-inquest-different-public-inquiry-grenfell-tower-victims-a7794661.html

They are not about apportioning blame: inquests establish what happened and who should be held responsible remains a matter for criminal and civil courts.

http://www.coronerscourtssupportservice.org.uk/faq-s/index.html

The Coroner is limited by law in what s/he may do. An inquest is a fact-finding inquiry. It is not a trial. The purpose of an inquest is set out in section 11(5) of the Coroners Act:

 

An inquisition…

(b) shall set out, so far as such particulars have been proved –

(i) who the deceased was; and

(ii) how, when and where the deceased came by his death;

 

The relevant law is also contained in the Coroners Rules 1984:

Rule 36 (1) The proceedings and evidence at an inquest shall be directed solely to ascertaining the following, namely –

(a) Who the deceased was;

(b) How, when and where the deceased came by his death;

© The particulars … required by the Registration Act to be registered concerning the death

(2) Neither the coroner nor the jury shall express any opinion on any other matter”

 

Rule 42

No verdict shall be framed in such a way as to appear to determine any question of –

(a) criminal liability on he part of a named person

(b) civil liability

n every Jury inquest, the Coroner decides matters of law and procedure and the Jury decides the facts of the case and reaches a verdict. The Jury cannot blame someone for the death. If there is any blame, this can only be established by other legal proceedings in civil or criminal courts. However, the Jury can record facts that make it clear that the death was caused by a specific failure of some sort or by neglect.

Even serving a Rule 43 notice doesn’t apportion blame ......

Where did I suggest that, then?

 

http://www.independent.co.uk/news/uk/what-is-an-inquest-different-public-inquiry-grenfell-tower-victims-a7794661.html

 

http://www.coronerscourtssupportservice.org.uk/faq-s/index.html

 

Even serving a Rule 43 notice doesn’t apportion blame ......

The above would not be in the slightest bit relevant, its completely different, the complete opposite when you consider that a number of individuals will be held accountable for that disaster, and rightly so, make your mind up mate, you advocate the importance of a coroner but when you are put right, you move the goalposts. make your mind up.

lets gets back on track, are you saying that in this case and giving the cause of death, and regardless of where it happened, [ hospital ] the police should not have been involved immediately?, a simple YES or a simple NO.

Your earlier school of thought about where the death occurred and for reasons that I have already giving, is not a reason why the police should not have investigated, they like the hospital had an obligation to act correctly, in fairness to the police if the hospital did not report the event, what does that say?

Can I remind you that the poor man who died did not die because of what he went into hospital for, do you accept that, or like everyone else in your world, the coroner got it wrong and as per norm you are always right.

Should the police have been involved???????????

I’ve answered before : there was no need for the police to be involved on the facts stated.

The hospital or family could have involved the police if they chose.

As for : “the coroner got it wrong and as per norm you are always right”

Who is saying the coroner has got it wrong?

I’m not, and I can’t be sure (due to your inability to make clear statements) if you are saying the Coroner is wrong or right .....

As for “The above would not be in the slightest bit relevant, its completely different, the complete opposite when you consider that a number of individuals will be held accountable for that disaster, and rightly so, make your mind up mate, you advocate the importance of a coroner but when you are put right, you move the goalposts. make your mind up“ :

I’m sure you are trying to make a point or create a logical argument, but it comes across as a random rant.

Bazza and spitfire, could we remember please that this is an advice thread and not a discussion one? This is an interesting debate, but maybe we should wait for the OP to return or you should have your own discussion thread.

HB

Sure, HB.

If the notes remain missing, they are paper notes.

There may be some electronic notes : especially a ‘Datix’ report, that may still be available, and the family can consider asking for it.

I also hope that those links I’ve provided are useful, and give the family a realistic view on what they can expect as an outcome (a verdict, perhaps a ‘narrative verdict’ but not a finding of blame).

Thank you Bazza.

HB

Whilst I am not the type to adjudge or to mislead, you here everyday how the overstretched NHS make common mistakes which has to be accepted.

But sometimes as in any profession you will get that element who will cover up when it is clear mistakes have been made.

If my dad went into hospital with a chest infection but lost his life and on the report of a coroner,

I like the OP and his family would wants answers,

they cannot give the answers,

however others who are obliged to investigate are not investigating and those who are obliged to provide the evidence to provide those reasons are not doing that, the OP needs to know what rights he has has and what rights his dad had and still has.

Any advice for the OP?