Ellie Clark
6 Mar 2018 · Coroner Wendy James · Gwent
The coroner's concerns
1. lack of effective and robust care plan
“The lack of an effective and robust care plan. No one clinician was allocated to oversee the long-term management and care of [the deceased]'s medical condition. She was dealt with by three different doctors at the surgery within a period of 5 days leading up to her death.”
2. turned away from emergency appointment
“[the deceased] was turned away from an emergency appointment for being late without any clinical assessment or safeguarding advice being given.”
3. delay in triage for emergency appointment
“A delay in [the deceased] being triaged for an emergency appointment resulting in insufficient notice being given a to enable timely attendance at the appointment.”
4. lack of effective and robust triage system
“The lack of an effective and robust triage system. The receptionist who spoke with a. the telephone and the doctor who triaged [the deceased] were different to the receptors ia spoke with at the surgery and the doctor with whom the emergency appointment was booked. Furthermore, the triage notes were not made available to the doctor in readiness for the emergency appointment.”
5. severe/life threatening asthma not prominently noted
“A note that [the deceased] had severe/life threatening asthma was not placed on her medical notes in a prominent position.”
6. lack of support for staff challenging decisions
“Support staff did not feel they would be supported if they challenged a doctor's decision or sought a second opinion.”