David Little
28 Jun 2016 · Coroner John Pollard · Manchester (South)
The coroner's concerns
1. failure to keep clear records of inpatient radiology transfers
“There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to”
2. lack of clear diagnostic pathway and monitoring plan
“The hospital had no clear diagnostic pathway or monitoring plan on admission”
3. inadequate differential diagnosis handling
“Where there is a differential diagnosis of two or more potential conditions, the staff simply treated the least serious and assumed that was the correct diagnosis”
4. poor staff communication
“The communication between and among staff generally was poor but especially between the radiology department and the clinicians and nurses”