Frederick Sutton
27 Aug 2015 · Coroner John Pollard · Manchester (South)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. insufficient staffing
“The staffing levels in the hospital during his stay seemed to be less than optimal.”
2. procedure failure
“Whilst there is a procedure for escalation of the shortage of staff, this was either not fully understood or not properly put into effect.”
3. nursing note oversight
“There was clear evidence that a nurse had failed to read (or read properly) the nursing notes.”
4. system incompatibility
“The computerised note keeping system used in the Emergency Department is not able to”
5. drug administration training
“The patient required the administration of cyclazine and there was an obvious problem with the (lack of) training of the staff in this regard.”
6. cardiac arrest response
“The patient suffered a cardiac arrest and there was a lack of understanding amongst nursing and medical staff as to how this ought to have been responded to.”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“The computerised note keeping system used in the Emergency Department is not able to”
Later report
“The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.”
Responses
No published response was found on judiciary.uk.