Cerith Pugh

“referrals to consultants at Withybush General Hospital are routinely being dealt with by middle grade doctors and, if in the opinion of the middle grade doctor, the matter then needs a referral to a consultant only then is the matter passed to a consultant. All consultant referrals should be seen by consultants in the first instance. Expert evidence received at the inquest described this practice as not being best practice”

“liver function tests were requested but the Health Board declined to undertake these for reasons of demand management on the basis tests had been done some three days earlier. Expert evidence received at the inquest was highly critical of this practice”