Elaine Bradbrook

1. 1. failure to escalate and act on deteriorating condition

   “There was a failure to escalate and act on [the deceased]'s deteriorating condition from at least 14.00 on 22 April 2017, when her NEWS was 6, and her GCS is also likely to have dropped.”

2. 2. failure to record GCS and conduct clinical review

   “There was a failure to record a single GCS after 14.00, when her level of consciousness dropped. I found no evidence of any clinical or nursing review after this time.”

3. 3. failure to discuss condition with neurosurgeons before transfer

   “There was a failure to discuss [the deceased]'s condition with neurosurgeons in Nottingham again before she was transferred to Nottingham, when it was clear that her condition had deteriorated significantly.”

4. 4. failure to reduce transfer risks

   “There was a failure to reduce the risks during transfer - a patient with a GCS of 4 and a history of vomiting was handed over to ambulance staff with an unprotected airway and without clinical review, or escort.”

5. 5. lack of internal investigation and family contact

   “The trust appears not to have appreciated the significance of these issues. It has not carried out any internal investigation, nor contacted [the deceased]'s family in line with its duty of candour. I am concerned that there has been no opportunity for learning within the trust, following these serious failures.”

6. 6. procedure for investigations needs review

   “The trust's procedure for carrying out High Level Investigations and Serious Untoward Incident Investigations should be reviewed.”

Linked reports