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recurance

Jean Stockley

12 Aug 2016 · Coroner Karen Harrold · West Sussex

The coroner's concerns

  1. 1. failure to review patient when NEWS score increased

    “On9 April, Mrs [name redacted] respiratory condition was clearly deteriorating necessitating critical care review who recommended careful and consistent observation of principally her oxygen saturation levels. The NEWS score was a vital tool to alert clinical staff to an acute change yet despite the fact the score went from 4 to 8, the junior doctor did not review the patient. | heard evidence from nursing staff that the doctor felt the patient may simply have been anxious. This suggests a potential”
  2. 2. unclear escalation of care pathway

    “Further, although the nurse quite rightly telephoned a doctor it was far from clear whether the right doctor had been contacted. The national NEWS forms were in use at the time of Mrs [name redacted] death to record observations but the policy that governed their use was the 2012 MEWS Escalation Policy and the two policies were different. From evidence heard from both doctors and nurses, it suggests the need to revisit how the NEWS policy is applied locally especially around which doctor should be”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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