Evadney Dawkins
21 Dec 2020 · Coroner Graeme Irvine · East London
The coroner's concerns
1. lack of renal monitoring
“On 22nd July 2018, Mrs [name redacted] was assessed to require renal monitoring, incorporating; a) Regular blood tests b) A renal ultrasound c) Fluid intake/output monitoring”
2. failure to classify serious incident
“The Trust's governance systems did not assess to a case as a Serious Incident requiring investigation for 2 years”