Elizabeth Hutchins
19 Apr 2023 · Coroner Maria Voisin · Avon
The coroner's concerns
1. medical patient not seen for 4 days
“She was not seen by a doctor for 4 days, she should have been. He would expect all patients to be seen on a working day. A medical patient not seen for 4 days is not right.”
2. elevated troponin with chest pain and abnormal ECG
“She had chest pain an abnormal ECG and an elevated Troponin. - Her heart was under strain and she was not treated at the time”
3. delayed cardiology review and ACS treatment
“she should have been reviewed by cardiology; had ACS treatment; monitored carefully; the risk of a second event is reduced by the ACS treatment, it might have made a difference”
4. absence of hospital at night team
“The hospital at night team, to assist with management of the hospital at night, take calls from wards, log and triage the calls, coordinate the night team, send clinicians tasks - this is still to be put into place, funding has not been secured for this”
5. missing ACS specialist nurse practitioner role
“The acute cardiac syndrome (ACS) specialist nurse practitioner role - this is not in existence at this time which I am told would be an excellent compliment for the teams and support staff during the daytime hours”