Annette Krasinsky-Lloyd

1. 1. inadequate A&E governance and treatment

   “It was clear from the evidence that the governance and rapidity of treatment in A&E was inadequate. The SHO who initially provided care to Mrs [the deceased] was left un-supervised for an extended period resulting in a delay of 90 minutes before the relevant A&E consultant engaged in the care of the patient and 3 appropriate investigations undertaken to establish the nature of the deceased's condition”

2. 2. delays in test results and assessment

   “Notwithstanding (1) there were additional delays in obtaining results of tests and the conduct of an appropriate assessment of the deceased's condition. This in turn led to delays in reversing the deceased's anti-coagulation therapy and administering blood transfusions.”

3. 3. inadequate A&E monitoring causing cannula fissure

   “At the time the on call consultant for medicine received Mrs [the deceased] into his care, she had further deteriorated, including the fissuring of her cannula leading to poor intravenous access. Between the end of the crash call at 1147 hours and when Mrs [the deceased] was transferred from the A&E department (around 1330 hours), the monitoring of Mrs [the deceased] by the A&E department was inadequate giving rise to the complication relating to poor intravenous access.”

No published response was found on judiciary.uk.