John Slope
7 May 2021 · Coroner Yvonne Blake · Norfolk
The coroner's concerns
1. absence of documented salivary bypass tube
“no method of noting in the medical records that a salivary bypass tube is in the patient's body”
2. lack of visual alert for bypass tube
“no method of showing staff in the notes that a patient has this prosthesis and that no thought had been given to this simple measure e.g. a rubber stamp stating patient has a bypass tube in situ to be ticked and signed”
3. inadequate medical documentation
“quality of the documentation pre and post operatively is of poor quality and would not assist other staff to find out what treatment had been given”
4. missing consent documentation for bypass tube
“there is nowhere on the consent form or the anaesthetic checklist for the presence of a tube to be asked about and documented”
5. failure to escalate patient concerns
“clinical specialist nurses did not contact anyone or document the concerns raised by Mr [name redacted] in March 2020”
6. lack of external treatment summary
“hospital did not request a summary of Mr [name redacted] treatment at a different hospital before commencing the procedures”