Chloe Tapp

“Neurology departments are so overwhelmed and/or understaffed that a vulnerable young girl (particularly so during the Covid-19 pandemic), was not referred in a timely manner to adult neurology services and in fact, it transpired a referral had not been made at all. This appears to have been done for the first time in August 2021.”

“An initial consultation with a complex non-verbal patient was arranged over the telephone, notwithstanding the concerns about a tremor which would have required visual assessment.”

“An overworked consultant under considerable pressure, did not have time before or during the consultation to establish the dose that [the deceased] was taking and/or apply the appropriate conversion factor, for medications that can interact negatively at higher doses.”

“No note was made of the tapering regime for the medication change in [the deceased]'s notes.”

“A handwritten note of a tapering regime based on incorrect doses was sent to [the deceased].”

“The same regime was repeated in a letter to the Epilepsy Nurses, but this letter was not received until October 2021 (in paper form) as the initial email was sent to an address that no longer existed.”