John Leyin
16 Dec 2014 · Coroner Caroline Beasley-Murray · Essex
The coroner's concerns
1. lack of dissemination of Trust Policy and NPSA Guidance
“There was a failure on the part of the Hospital to ensure the dissemination of Trust Policy and NPSA Guidance to all staff”
2. weaknesses in training systems
“There were weaknesses in the training systems in place”
3. lack of verification of staff training for procedures
“Checks were not made as to whether or not staff were up to date in their training for carrying out procedures such as the insertion of a nasogastric tube”
4. insufficient awareness of trained staff availability
“At any one time there seemed to be a lack of knowledge as to how many trained staff were on duty to carry out such procedures”