Harold Elvidge

1. 1. use of wrong fluid type causing patient harm

   “itis clear that much work has been done by the Adult Critical Care team to learn from the mistakes made in this case. It is now not possible to obtain 500 mi bags of 5% dextrose fiuid without the input of a pharmacist, and they are not stored in the same place as 500m! bags of normal saline”

2. 2. inconsistent availability of Omnicell cabinets across critical care areas

   “The evidence suggested that Omnicell cabinets may be available soon in E12 at the QMC. It was however clear that, although Critical Care at the City campus has Omnicell cabinets in place, this is not the case across the trust, nor even all all critical care areas in the trust”

3. 3. future deaths due to inadequate safety standards in non‑critical care areas

   “Whilst mindful of the cost implications involved, | am concerned about the risk of future deaths occurring in other parts of the trust which may not have as robust a safety standard as Critical Care (certainly at the City Hospital campus) now appears to have”

4. 4. lack of trust‑wide safe storage policies for fluids

   “Itis not for me to make specific recommendations regarding the purchase of specified equipment, but a trust-wide review of policies for safe storage of different types of fluids would reduce the risk of a similar tragedy occurring in future.”

No published response was found on judiciary.uk.