David Morris

1. 1. delayed cancer diagnosis and treatment

   “Mr [name redacted] diagnosis and treatment for cancer was delayed due to poor organisation and communication at the Trust.”

2. 2. delayed sepsis treatment

   “During the evening of 3rd May 2022 going into the early hours of 4th May 2022, Doctors and nurses failed to identify the extent of Mr [name redacted] gastrostomy leak and the onset of sepsis. After identifying symptoms of sepsis, staff failed to treat and escalate Mr [name redacted] care resulting in a delay of three and a half hours before a medical review commenced emergency treatment.”

3. 3. inadequate clinical records

   “During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent. The absence of clear records impeded the effective investigation of this death by the Trust's governance teams and the Coroner.”

4. 4. unfit investigation report

   “The initial serious investigation report into Mr [name redacted] death was unfit for purpose. The report to investigate or even identify the Registrar who reviewed Mr [name redacted] on the evening of 3rd May 2022. Since then, no effective review has been undertaken by the Trust upon how this deficient report gained executive approval.”

5. 5. lack of controlled drug management systems

   “The Trust did not have effective controlled drug management systems in place to detect a prolonged and persistent course of conduct from an employed nurse who was stealing and self- administering controlled drugs in the workplace.”

Linked reports