Carol Welch
11 Jan 2023 · Coroner Linda Lee · Warwickshire
The coroner's concerns
1. subarachnoid haemorrhage masquerading as migraine
“The need to raise awareness of subarachnoid haemorrhage masquerading as a migraine and the need to investigate possible neurological findings”
2. lack of familiarity with Royal College guidance on repeat emergency department visits
“Doctors were not familiar with the Royal College Guidance that there is a need to discuss with a consultant, all patients who unexpectedly return within 72 hours of discharge from the emergency department”
3. inadequate prominence of patient safety issues in aide memoire
“The document (described as an aide memoire) which notified all doctors of the Royal College Guidance referred to other matters such as punctuality and staff sick leave. Matters critical to patient care were not clearly identified and given appropriate prominence”
4. lack of confirmation of understanding and compliance with learning points
“It is requested that consideration be given to ensuring that where learning points relating to patient safety are identified, they are not only circulated to existing and future members of the team but that all doctors confirm their understanding and compliance”
5. inadequate training assessment for senior doctors on critical guidelines
“It is also requested that there is a review of training plans for more senior doctors who would not be familiar with Royal College and other guidelines, to ensure that guidance critical to patient safety is easily identified and that familiarity with any such guidance is assessed”