Anna Walker

1. 1. inadequate post-operative monitoring

   “the procedure confirmed that the post-operative checks were not compliant with the Trust's Protocol. Only 2 complete checks were carried out (at 10:45 and 11 am). The check at 11:50 was not complete. There were no further post-operative checks documented on the observation sheet after 11:50, despite the concerning observations at that time. The Consultant [name redacted] gave evidence that had the appropriate post- operative checks been carried out, the bleed was likely to have been”

2. 2. failure of porters to collect patient

   “The Consultant [name redacted] confirmed that in his opinion, the reasons for the failure to carry out the required observations were: |. The failure of the porters to collect the patient. He stated that the failure of the porters to attend, was reported as a serious incident. He stated that this issue has still not been resolved and is an ongoing issue within the Trust”

3. 3. chaotic radiology department workflow

   “The Consultant described a”

4. 4. inappropriate environment for monitoring

   “He stated that Mrs [name redacted] was not in the appropriate environment for post- operative monitoring”

5. 5. lack of adherence to recommended observation frequency

   “HS (husband) provided guidance from the BMJ setting out the suggested post-biopsy observations. This included observations every 15 minutes for the first 2 hours and then every 30 minutes for 2 hours thereafter. | would respectfully request that the Trust consider the Policy that it has in place, in light of the BMJ recommendations.”

6. 6. inconsistent incident reporting classification

   “2 incident report forms were completed in relation to Mrs [name redacted] death. (Form number 52695 and Form number 53952). The outcome of the main incident report form (52695) concluded that appropriate care was given and this was not considered a Serious Incident. This conclusion was at odds with the evidence heard from the Trust's Consultant [name redacted]. It was also at odds with the Trust's Protocol for post-operative monitoring and the recorded post-operative observations.”

No published response was found on judiciary.uk.