Audrey Daws
9 Jun 2014 · Coroner Andrew Cox · Plymouth, Torbay & South Devon
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed chest X-ray result
“The need for Mrs [name redacted] to undergo a chest X- ray and for the result to be checked appears to have been lost as medical staff have changed at the end/start of consecutive shifts”
2. delayed chest X-ray ordering
“A chest X-ray should have been ordered at the time of Mrs [name redacted] admission into the emergency department”
3. delayed result review
“once the X-ray was performed, the result was not seen by medical staff for over 24 hours”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“once the X-ray was performed, the result was not seen by medical staff for over 24 hours”
Later report
“There was a delay of 5 days in the formal reporting of the original X-ray;”
Responses
2014-0318-Plymouth-Hospital-NHS-Trust.pdf ↗· Plymouth Hospitals NHS Trust
Stated action
“We have made a number of changes to the handover process, both in relation to medical and nursing procedures.”