FT’s record keeping cited as a concern by five inquests since 2016

Over the last three years, Blackpool Teaching Hospitals Foundation Trust has received warnings from coroners about poor record keeping in at least five separate cases, HSJ has learned.

In a letter, published by the Courts and Tribunals Judiciary last month, the senior coroner for Blackpool and Fylde wrote to the trust to say poor record keeping had hindered investigations into the death of Tina Tait, who died following complications arising from ovarian cystectomy surgery in May 2018.

Alan Wilson found the record keeping issues did not contribute to her death, but wrote: “The concern I have is that there is a risk of future deaths because the opportunity to learn valuable lessons following a death is being compromised by issues pertaining to the quality of record keeping.”

He said investigators had found the records to be “poor and illegible”, and referred to two previous cases in 2017 where there had been similar issues.

In one of these cases, he said an inquest had to be held without documentation due to the trust being unable to locate it. In another, the trust had told the coroner that internal investigations had been undertaken in the absence of some patient records.

In another case, the area’s assistant coroner Tim Holloway cited problems with record keeping in the case of James Fletcher, who died in July 2018.

Again, the issues were not thought to have contributed to his death, but Mr Holloway wrote: “Complete records were not provided to the court in accordance with directions given prior to the inquest. It was understood from the trust that complete records were unavailable and yet it transpired on the first day of the inquest that further records were available but had not been found and produced previously.

“I am concerned that the system of record keeping gives rise to a risk that patients’ records which are material to their ongoing care will be lost or otherwise inaccessible.”

In another inquest in 2016, into the death of Barry Thompson, assistant coroner Clare Doherty warned the provider about patient records that were “inaccurate, infrequently made, disjointed and incomplete”, which she said caused them to be unreliable and affected continuity of care.

The CQC has also cited similar issues following an inspection in June, writing in its initial feedback to the trust: “Systems to manage and share care records and information were not always consistent. Staff did not always have the complete information they needed before providing care and treatment.

“We saw examples of records being illegible, difficult to follow with loose pages. Some records such as the allergy attention/significant event card was not being completed. Records were not stored securely, and we observed a relative accessing another patient record.”

The trust, which reported a £9m deficit last year, is planning to procure an electronic document management system to replace paper notes, which it believes will improve record keeping and information sharing.

A spokesman said there had been problems taking the project forward due “inadequate funding being available and the need to identify adequate estate to create the scanning bureau”, but added that a “revised buisness case” is due to go to the board in early September. He said the budget for the scheme has not yet been set.

The trust currently has an electronic patient record in its emergency department, provided by IMS Maxims, and is “finalising plans to deploy this solution to the rest of the organisation”.