Deline Etienne
12 Sept 2022 · Coroner Graeme Irvine · East London
The coroner's concerns
1. chaotic nursing response to cardiac arrest
“The response of the nursing team to a cardiac arrest was chaotic, and failed to follow trust and national guidelines designed to maximise the effectiveness of resuscitation”
2. failure to escalate raised blood pressure for medical review
“Whilst Mrs [name redacted] was an inpatient, the ward failed to escalate episodes of raised blood pressure for medical review in contravention of trust policy”
3. lack of VTE risk assessment during inpatient care
“At no time during the two periods of Mrs [name redacted] inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy”
4. chest pain escalation without documented medical review
“An episode of chest pain identified by nursing staff on 21 st April 2021 was escalated for medical review, no evidence of such a review exists”
5. failure to admit error regarding DNACPR status
“When nursing staff discovered that they had fallen into error by asserting that Mrs [name redacted] had a DNACPR in place the matter was discussed with ward management on the morning of 7th May 2022. Despite that, the error was not admitted”