Gillian McKinlay

1. 1. lack of clear responsibility for overall patient clinical care

   “For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care”

2. 2. absence of mandated clinical review

   “EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the other clinical teams”

3. 3. failure to escalate after failed NG tube placement and EWS review

   “When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy”

4. 4. inadequate Trust response to escalation failure

   “the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that”

5. 5. lack of documented investigation actions

   “the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken d.”

6. 6. unsubstantiated claim of correct EWS escalation

   “the report states that there was a”

No published response was found on judiciary.uk.