Catherine Kennedy

“Miscommunication in the course of that conversation in combination with other factors, played a part in the fact that over 14 hours elapsed between staff first being informed of the overdose and Mrs [name redacted] being reviewed by a doctor.”

“the Trust does not appear to consistently have in use a communication paradigm (such as the SBAR paradigm introduced by the United States Navy and widely of application across the NHS) as to the content and documentation of key communications”