Adrian Ashford
7 Feb 2020 · Coroner Andrew Harris · London Inner South
The coroner's concerns
1. clinical misjudgment leading to missed opportunities
“individual matters of clinical misjudgment, still less retrospective missed opportunities do not in themselves trigger my statutory duty”
2. lack of systemic change in practice
“there was no change in his practice, other than increased awareness”
Responses
2020-0054-Response-from-Lewisham-and-Greenwich-NHS-Trust.-Redacted.pdf ↗· Queen Elizabeth Hospital
Stated action · May-June 2019
“The Trust has now implemented a trust-wide electronic patient record system (since May-June 2019). The system enables weight to be consistently recorded electronically which can then be observed by all staff within the Trust”
Stated action
“A new standard operating procedure for managing suspected upper GI bleeding has been produced and circulated”