Clara Winter
28 May 2024 · Coroner Kerrie Burge · South Wales Central
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. delayed escalation and inadequate fluid balance monitoring
“significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts and recommended that all registered nurses from surgical wards should attend an 'Acutely Unwell' study day”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“(4) The failure at triage to escalate this referral to seeing a doctor within 10 mins of admission.”
This report
“The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts”