Daniel Xavier

“Prior to Mr [name redacted] discharge from hospital on the evening of 21 st October 2021 , the deceased's venous blood gas results were not considered and acted upon by staff. The results, available from 13.17, indicated that Mr [name redacted] had a dangerously elevated creatinine level. Evidence heard at inquest indicated that had the results been considered, Mr [name redacted] would not have been discharged, he would have been escalated to the resuscitation department. Further, the Trust accepted that had the creatin”

“Mr [name redacted] referral to the surgical team by his GP was chaotic. No telephone contact was made between the GP and the on call surgical team. Mr [name redacted] was therefore triaged by a ED nurse and subsequently, a rapid assessment team junior doctor before he was brought to the attention of the surgical team. Despite these assessments, no formal handover was provided to the surgical team, setting out the extent of the history, clinical observations and diagnostic processes that had previously taken”

“Due regard was not given to Mr [name redacted] learning disability during his admission on 21 st October 2021 .1n sufficient time and care was taken to establish a clear history from the patient, most pertinently his 7-day history of constipation.”