Joanne Stones

“The ambulance service pre-alerted the hospital regarding [the deceased]'s serious condition but this did not result in her being prioritised and placed in Resus on arrival. [the deceased] was wearing two medic alert bracelets to draw attention to her diagnoses of APS and AD but these were not observed by the treating team. There were no visible 'red flags' on [the deceased]'s medical records, highlighting her APS and AD diagnoses to the treating team. The treating doctor relied on a very sick patient to confirm any underlying medical conditions. There was no liaison with Rheumatology, who had extensive knowledge and experience of [the deceased] and how to treat her conditions.”

“There was delay in [the deceased] receiving fluids, which led to hypoglycaemia which was then not treated promptly.”

“It was not clear from the medical notes that staff treating [the deceased] had considered the relevance of her APS and AD in her treatment plan.”