Dave Onawelo
27 Aug 2024 · Coroner Graeme lrvine · East London
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. failure to identify critically ill patient with sickle cell anaemia
“The Trust failed to adequately identify a critically ill patient with a pre-existing co-morbidity, sickle cell anaemia, that carried with it a high risk of acute deterioration.”
2. over-reliance on NEWS algorithm and lack of clinical curiosity
“Factors in the Emergency Department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed the outcome.”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“Factors in the Emergency Department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed the outcome.”
Later report
“There was no timely triage of Majors patients by the medical team, to ensure that those with the greatest potential of clinical decline are picked up quickly and appropriate investigations commenced at an early stage.”
Closely relatedConfidence 0.80 · moderate
This report
“Factors in the Emergency Department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed the outcome.”
Later report
“There is no electronic observation system in place within the A&E department of Whipps Cross Hospital (such as Live Note). Patients presenting with high NEWS scores are not therefore automatically brought to the attention of clinical supervisors.”
Responses
2024-0470-Response-from-DHSC.pdf ↗· Barts Health NHS Trust
Stated action
“the trust will be responding to you directly on the steps they are taking locally; this includes action to help improve the awareness and care provided in the emergency department for patients with sickle cell anaemia”