James Mallett
16 Mar 2017 · Coroner Yvonne Blake · Norfolk
The coroner's concerns
1. inadequate neurological observations
“It became clear during evidence that the nursing staff on duty on 13 November 2016 were not able to understand and carry out proper neurological observations”
2. delayed medical assessment
“There was no apparent urgency to secure the prompt attendance of a doctor to assess the patient”
3. lack of documentation
“The nursing staff made no contemporaneous notes for a period of five hours on the system so there Was little information about the timings of their actions”
4. insufficient staff competence
“The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr [name redacted]”
5. absence of competency monitoring systems
“There do not appear to be systems in place at the hospital which are sufficient to recognise when nurses are so inexperienced and/or lacking in training that they cannot undertake basic observations on a patient following an injury of this kind”