Geoffrey Parry
7 Oct 2015 · Coroner Andrew Barkley · Cardiff and the Vale of Glamorgan
The coroner's concerns
1. unavailable ECG results
“During the evidence it transpired that an ECG test which was undertaken on 21* April 2015 was not available to the reviewing consultant anaesthetists prior to surgery”
2. disconnected noradrenaline line
“During the evidence it became clear that whilst in intensive care an intravenous line administering noradrenaline was disconnected from Mr [name redacted] which caused his blood pressure fo drop significantly to the point of requiring cardiopulmonary resuscitation”
Responses
2015-0400-Response-by-University-Health-Board.pdf ↗· Cardiff and Vale University Health Board
Stated action · December 2015
“The University Health Board has taken the opportunity to completely review the systems and processes in place for the storage of ECG investigations. The Cardiac Physiology Department hosts a system called MUSE which allows for electronic storage of ECGs. Currently, a limited number of departments utilise this system. Bwrdd lechyd Prifysgol Caerdydd a'r Fro yw enw gweithredal Bwyrdd lechyd Lleol Prifysgol Caerdydd a'r Fro Cardiff and Vale University Health Board is the operational neme of Cardiff and Vate University Local Health Board sage An upgrade to the MUSE software is anticipated to be released shortly.”