Frank Medley
2 Mar 2021 · Coroner Dr James Adeley · Lancashire and Blackburn with Darwen
The coroner's concerns
1. ineffective adverse outcome detection for transferred patients
“The Trust has an ineffectual system to detect adverse outcomes where the patient is transferred to a tertiary centre for treatment and subsequently dies”
2. lack of family consultation on death concerns
“The Trust's review of this case was seriously deficient in the following instances: a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest”
3. report delay beyond NHS guidance
“The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance”
4. inappropriate case allocation to structured judgement review
“The case was inappropriately allocated to a structured judgement review”
5. substantial factual inaccuracies in incident summary
“The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading”
6. failure to document sepsis pathway triggers and actions
“Mr [name redacted] death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that: i. the EWS score was sufficient to trigger the septic shock pathway; ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of”