Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate supervision of junior medical staff
The earlier warning
Stephanie Daniels · 13 Dec 2013 · Nigel Meadows, Manchester City
“| am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff. Two junior doctors were asked to attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication.”
What was promised
Stated action 1 · response to Stephanie Daniels (13 Dec 2013) · stated timescale: none stated
“I expect all healthcare professionals working in local Trusts to be fully trained and aware of the existing protocols in their local Trust. It is for local healthcare organisations to ensure that all staff are trained to the appropriate standard.”
judiciary.uk/…/2013-0353-Response-by-Department-of-Health.pdf
What recurred
- 25 Oct 2021 · Margaret Kinsey · Alison Mutch · Closely related · confidence 0.86 (high)
The clearest link, quoted from both reports:
Earlier · Stephanie Daniels · 13 Dec 2013
“| am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff. Two junior doctors were asked to attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication.”
Later · Margaret Kinsey · 25 Oct 2021
“The inquest heard that due to the time of her arrival in the Emergency Department on 11th December 2020 consultants were not on site. The most senior doctors available were middle grade and the number available at that time of night was significantly reduced.”
What happened next
No web check of the stated actions has been published for this chain.