Joan Mary Jones
20 Sept 2013 · Coroner Catherine Mason · Leicester City and South Leicestershire
The coroner's concerns
1. failure to escalate care
“The staff did not escalate Mrs [name redacted]' care when they should have done”
2. lack of communication
“The staff did not communicate all that was known to them and therefore attending health care professionals were unable to make fully informed decisions”
3. inadequate care package
“Due to the lack of communication, an appropriate package of care was not put in place for Mrs [name redacted]”
4. potential future death
“These omissions (failure to escalate and the lack of communication with other attending health care professionals) together or alone, could in future circumstances cause or contribute to death”