Elsie Woodfield
21 Jun 2021 · Coroner Ian Arrow · Plymouth Torbay and South Devon
The coroner's concerns
1. inconsistent consenting for endoscopy
“There appears to be a significant discrepancy between clinicians on the consenting procedure for the identical treatment of endoscopy”
2. aspiration not excluded
“A 'sip test' to exclude aspiration was not performed, and there has been no evidence that this had been noted or remedied at the Trust”
3. failure to act on complication warning
“A doctor did not take action when viewing an endoscopy report which contained an indication of a possible dangerous complication”
4. inadequate record keeping
“Appropriate records were not kept, or were not properly transferred, by senior staff”