Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate escalation of clinical care
The earlier warning
Samantha Beach · 21 Oct 2015 · Katy Skerrett, Gloucestershire
“The clinical care provided to [name redacted] in the obstetric department was not escalated appropriately to more senior colleagues,”
judiciary.uk/prevention-of-future-death-reports/samantha-beach
What was promised
No published response from Gloucestershire Hospitals NHS Trust was found for the earlier reports.
What recurred
- 6 Apr 2017 · Steven Amos · Katy Skerrett · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Samantha Beach · 21 Oct 2015
“The clinical care provided to [name redacted] in the obstetric department was not escalated appropriately to more senior colleagues,”
Later · Steven Amos · 6 Apr 2017
“Whether there is appropriate escalation of care given to a patient who acutely deteriorates during the night shifts over the weekend period.”
What happened next
No web check of the stated actions has been published for this chain.