James Pearson

“Having had a CT scan at Birmingham Heartlands Hospital on 14th June 2023, [the deceased] was diagnosed with severe pelvic injuries, and the Radiologist reported findings which were consistent with an active pelvic bleed.”

“During the inquest, I heard that [the deceased] was attached to a monitor, which was taking his observations every 15 minutes. None of these observations, however, were documented. This is of concern, as it is not possible to know at what point [the deceased] began to decline. I am concerned that lack of proper documented observations could lead to future deaths, as staff will not be able to follow the observation pattern and notice a decline in presentation.”

“I am therefore concerned that there were not enough Doctors in the department at the time, meaning that there is no resilience to deal effectively with more than one very unwell patient at any given time. If this is not addressed, there is a risk of future deaths.”

“the blood products at Birmingham Heartlands Hospital are not kept in the ED, and are kept some distance away, and could take up to 20 minutes to obtain after the major haemorrhage protocol is activated. Whilst this is unlikely to have affected the outcome for [the deceased], due to his sudden deterioration, I am concerned that a delay in obtaining blood products could lead to future deaths.”